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Practice Quesstion for Exam 2
Multiple Choice Identify the choice that best completes the statement or answers the question.
____ 1. A 39-year-old primigravida thinks that she is about 8 weeks pregnant, although she has had irregular
menstrual periods all her life. She has a history of smoking approximately one pack of cigarettes a
day, but she tells you that she is trying to cut down. Her laboratory data are within normal limits.
What diagnostic technique could be used with this pregnant woman at this time?
a. Ultrasound examination
b. Maternal serum alpha-fetoprotein screening (MSAFP)
c. Amniocentesis
d. Nonstress test (NST)
____ 2. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked
throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction
in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in
confirming the diagnosis?
a. Doppler blood flow analysis c. Amniocentesis
b. Contraction stress test (CST) d. Daily fetal movement counts
____ 3. A 41-week pregnant multigravida presents in the labor and delivery unit after a nonstress test
indicated that her fetus could be experiencing some difficulties in utero. Which diagnostic tool
would yield more detailed information about the fetus?
a. Ultrasound for fetal anomalies
b. Biophysical profile (BPP)
c. Maternal serum alpha-fetoprotein screening (MSAFP)
d. Percutaneous umbilical blood sampling (PUBS)
____ 4. At 35 weeks of pregnancy a woman experiences preterm labor. Although tocolytics are administered
and she is placed on bed rest, she continues to experience regular uterine contractions, and her cervix
is beginning to dilate and efface. What would be an important test for fetal well-being at this time?
a. Percutaneous umbilical blood sampling (PUBS)
b. Ultrasound for fetal size
c. Amniocentesis for fetal lung maturity
d. Nonstress test
____ 5. A 40-year-old woman is 10 weeks pregnant. Which diagnostic tool would be appropriate to suggest
to her at this time?
a. Biophysical profile
b. Amniocentesis
c. Maternal serum alpha-fetoprotein (MSAFP)
d. Transvaginal ultrasound
____ 6. A woman is undergoing a nipple-stimulated contraction stress test (CST). She is having contractions
that occur every 3 minutes. The fetal heart rate (FHR) has a baseline of approximately 120 beats/min
without any decelerations. The interpretation of this test is said to be:
a. Negative. c. Satisfactory.
b. Positive. d. Unsatisfactory.
____ 7. A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation
and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and
parity using the GTPAL system?
a. 2-0-0-1-1 c. 3-1-0-1-
b. 2-1-0-1-0 d. 3-0-1-1-
____ 8. A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and
symptoms of pregnancy likely will have:
a. Amenorrhea. c. Chadwick’s sign.
b. Positive pregnancy test. d. Hegar’s sign.
____ 9. The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of
pregnancy. The woman demonstrates understanding of the nurse’s instructions if she states that a
positive sign of pregnancy is:
a. A positive pregnancy test.
b. Fetal movement palpated by the nurse-midwife.
c. Braxton Hicks contractions.
d. Quickening.
____ 10. A woman is at 14 weeks of gestation. The nurse would expect to palpate the fundus at which level?
a. Not palpable above the symphysis at this time
b. Slightly above the symphysis pubis
c. At the level of the umbilicus
d. Slightly above the umbilicus
____ 11. During a client’s physical examination the nurse notes that the lower uterine segment is soft on
palpation. The nurse would document this finding as:
a. Hegar’s sign c. Chadwick’s sign
b. McDonald’s sign d. Goodell’s sign
____ 12. A number of changes in the integumentary system occur during pregnancy. What change persists
after birth?
a. Epulis c. Telangiectasia
b. Chloasma d. Striae gravidarum
____ 13. The nurse caring for the pregnant client must understand that the hormone essential for maintaining
pregnancy is:
a. Estrogen.
b. Human chorionic gonadotropin (hCG).
c. Oxytocin.
d. Progesterone.
____ 14. A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal
viability is called a:
a. Primipara. c. Multipara.
b. Primigravida. d. Nulligravida.
____ 15. The mucous plug that forms in the endocervical canal is called the:
a. Operculum. c. Funic souffle.
b. Leucorrhea. d. Ballottement.
____ 16. To reassure and educate pregnant clients about changes in their cardiovascular system, maternity
nurses should be aware that:
a. A pregnant woman experiencing disturbed cardiac rhythm, such as sinus
c. History of breast cancer 3 years ago
d. Human immunodeficiency virus (HIV) positive
____ 25. The nurse should be aware that the partner’s main role in pregnancy is to:
a. Provide financial support.
b. Protect the pregnant woman from “old wives’ tales.”
c. Support and nurture the pregnant woman.
d. Make sure the pregnant woman keeps prenatal appointments.
____ 26. What represents a typical progression through the phases of a woman’s establishing a relationship
with the fetus?
a. Accepts the fetus as distinct from herself—accepts the biologic fact of pregnancy
—has a feeling of caring and responsibility
b. Fantasizes about the child’s gender and personality—views the child as part of
herself—becomes introspective
c. Views the child as part of herself—has feelings of well-being—accepts the
biologic fact of pregnancy
d. “I am pregnant.”— “I am going to have a baby.”—“I am going to be a mother.”
____ 27. The nurse should be aware that the pinch test is used to:
a. Check the sensitivity of the nipples.
b. Determine whether the nipple is everted or inverted.
c. Calculate the adipose buildup in the abdomen.
d. See whether the fetus has become inactive.
____ 28. The phenomenon of someone other than the mother-to-be experiencing pregnancy-like symptoms
such as nausea and weight gain applies to the:
a. Mother of the pregnant woman. c. Sister of the pregnant woman.
b. Couple’s teenage daughter. d. Expectant father.
____ 29. A 22-year-old woman pregnant with a single fetus has a preconception body mass index (BMI) of
24. When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lb) since
conception. How would the nurse interpret this?
a. This weight gain indicates possible gestational hypertension.
b. This weight gain indicates that the woman’s infant is at risk for intrauterine growth
restriction (IUGR).
c. This weight gain cannot be evaluated until the woman has been observed for
several more weeks.
d. The woman’s weight gain is appropriate for this stage of pregnancy.
____ 30. Which nutrient’s recommended dietary allowance (RDA) is higher during lactation than during
pregnancy?
a. Energy (kcal) c. Vitamin A
b. Iron d. Folic acid
____ 31. A pregnant woman’s diet consists almost entirely of whole grain breads and cereals, fruits, and
vegetables. The nurse would be most concerned about this woman’s intake of:
a. Calcium. c. Vitamin B 12.
b. Protein. d. Folic acid.
____ 32. A woman has come to the clinic for preconception counseling because she wants to start trying to get
pregnant in 3 months. She can expect the following advice:
a. “Discontinue all contraception now.”
b. “Lose weight so that you can gain more during pregnancy.”
c. “You may take any medications you have been taking regularly.”
d. “Make sure that you include adequate folic acid in your diet.”
____ 33. Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an
infant with:
a. Spina bifida. c. Diabetes mellitus.
b. Intrauterine growth restriction. d. Down syndrome.
____ 34. With regard to protein in the diet of pregnant women, nurses should be aware that:
a. Many protein-rich foods are also good sources of calcium, iron, and B vitamins.
b. Many women need to increase their protein intake during pregnancy.
c. As with carbohydrates and fat, no specific recommendations exist for the amount
of protein in the diet.
d. High-protein supplements can be used without risk by women on macrobiotic
diets.
____ 35. In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing
insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the
client states:
a. “I will need to increase my insulin dosage during the first 3 months of pregnancy.”
b. “Insulin dosage will likely need to be increased during the second and third
trimesters.”
c. “Episodes of hypoglycemia are more likely to occur during the first 3 months.”
d. “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-
feeding.”
____ 36. In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes
that the most important factor affecting pregnancy outcome is the:
a. Mother’s age.
b. Number of years since diabetes was diagnosed.
c. Amount of insulin required prenatally.
d. Degree of glycemic control during pregnancy.
____ 37. In teaching the woman with pregestational diabetes about desired glucose levels, the nurse explains
that a normal fasting glucose level, such as before breakfast, is in the range of _____ mg/dl.
a. 60 to 90 c. 120 to 150
b. 90 to 120 d. 150 to 180
____ 38. In terms of the incidence and classification of diabetes, maternity nurses should know that:
a. Type 1 diabetes is most common.
b. Type 2 diabetes often goes undiagnosed.
c. Gestational diabetes mellitus (GDM) means that the woman will be receiving
insulin treatment until 6 weeks after birth.
d. Type 1 diabetes may become type 2 during pregnancy.
____ 39. Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus
are complicated but important to understand. Nurses should know that:
a. Insulin crosses the placenta to the fetus only in the first trimester, after which the
fetus secretes its own.
b. Women with insulin-dependent diabetes are prone to hyperglycemia during the
first trimester because they are consuming more sugar.
____ 46. Marfan syndrome is an autosomal dominant genetic disorder that displays as weakness of the
connective tissue, joint deformities, ocular dislocation, and weakness to the aortic wall and root.
While providing care to a client with Marfan syndrome during labor, which intervention should the
nurse complete first?
a. Antibiotic prophylaxis c. Surgery
b. -Blockers d. Regional anesthesia
____ 47. Women with hyperemesis gravidarum:
a. Are a majority, because 70% of all pregnant women suffer from it at some time.
b. Have vomiting severe and persistent enough to cause weight loss, dehydration, and
electrolyte imbalance.
c. Need intravenous (IV) fluid and nutrition for most of their pregnancy.
d. Often inspire similar, milder symptoms in their male partners and mothers.
____ 48. Because pregnant women may need surgery during pregnancy, nurses should be aware that:
a. The diagnosis of appendicitis may be difficult, because the normal signs and
symptoms mimic some normal changes in pregnancy.
b. Rupture of the appendix is less likely in pregnant women because of the close
monitoring.
c. Surgery for intestinal obstructions should be delayed as long as possible because it
usually affects the pregnancy.
d. When pregnancy takes over, a woman is less likely to have ovarian problems that
require invasive responses.
____ 49. A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should
concern her nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg
b. Weight gain of 0.5 kg during the past 2 weeks
c. A dipstick value of 3+ for protein in her urine
d. Pitting pedal edema at the end of the day
____ 50. A woman with preeclampsia has a seizure. The nurse’s primary duty during the seizure is to:
a. Insert an oral airway.
b. Suction the mouth to prevent aspiration.
c. Administer oxygen by mask.
d. Stay with the client and call for help.
____ 51. A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe
preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of
37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/
mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, “I’m so thirsty and
warm.” The nurse:
a. Calls for a stat magnesium sulfate level.
b. Administers oxygen.
c. Discontinues the magnesium sulfate infusion.
d. Prepares to administer hydralazine.
____ 52. A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion
for 8 hours. The nurse assesses the woman and documents the following findings: temperature of
37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of
155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician,
anticipating an order for:
a. Hydralazine. c. Diazepam.
b. Magnesium sulfate bolus. d. Calcium gluconate.
____ 53. What nursing diagnosis would be the most appropriate for a woman experiencing severe
preeclampsia?
a. Risk for injury to the fetus related to uteroplacental insufficiency
b. Risk for eclampsia
c. Risk for deficient fluid volume related to increased sodium retention secondary to
administration of MgSO 4
d. Risk for increased cardiac output related to use of antihypertensive drugs
____ 54. Nurses should be aware that HELLP syndrome:
a. Is a mild form of preeclampsia.
b. Can be diagnosed by a nurse alert to its symptoms.
c. Is characterized by hemolysis, elevated liver enzymes, and low platelets.
d. Is associated with preterm labor but not perinatal mortality.
____ 55. The perinatal nurse is giving discharge instructions to a woman, status postsuction curettage
secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the
next 12 months. The best response from the nurse would be:
a. “If you get pregnant within 1 year, the chance of a successful pregnancy is very
small. Therefore, if you desire a future pregnancy, it would be better for you to use
the most reliable method of contraception available.”
b. “The major risk to you after a molar pregnancy is a type of cancer that can be
diagnosed only by measuring the same hormone that your body produces during
pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer
more difficult.”
c. “If you can avoid a pregnancy for the next year, the chance of developing a second
molar pregnancy is rare. Therefore, to improve your chance of a successful
pregnancy, it is better not to get pregnant at this time.”
d. “Oral contraceptives are the only form of birth control that will prevent a
recurrence of a molar pregnancy.”
____ 56. Methotrexate is recommended as part of the treatment plan for which obstetric complication?
a. Complete hydatidiform mole c. Unruptured ectopic pregnancy
b. Missed abortion d. Abruptio placentae
____ 57. A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences
bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected
diagnostic procedure?
a. Amniocentesis for fetal lung maturity c. Contraction stress test (CST)
b. Ultrasound for placental location d. Internal fetal monitoring
Multiple Response Identify one or more choices that best complete the statement or answer the question.
Practice Quesstion for Exam 2
Answer Section
MULTIPLE CHOICE
1. ANS: A
An ultrasound examination could be done to confirm the pregnancy and determine the gestational
age of the fetus. It is too early in the pregnancy to perform the MSAFP, an amniocentesis, or an NST.
The MSAFP is performed at 16 to 18 weeks of gestation, followed by amniocentesis if the MSAFP
levels are abnormal or if fetal/maternal anomalies are detected. An NST is performed to assess fetal
well-being in the third trimester.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 194 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
- ANS: A
Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus
and the placenta. It is a helpful tool in the management of high risk pregnancies because of
intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because
of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman
whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or
congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic
disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies
complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at
some point later in this woman’s pregnancy, it is not used to diagnose IUGR.
PTS: 1 DIF: Cognitive Level: Analysis REF: 198 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment, Diagnosis
- ANS: B
Real-time ultrasound permits detailed assessment of the physical and physiologic characteristics of
the developing fetus and cataloging of normal and abnormal biophysical responses to stimuli. The
BPP is a noninvasive, dynamic assessment of a fetus that is based on acute and chronic markers of
fetal disease. An ultrasound for fetal anomalies would most likely have occurred earlier in the
pregnancy. It is too late in the pregnancy to perform an MSAFP. Furthermore, it does not provide
information related to fetal well-being. Indications for PUBS include prenatal diagnosis or inherited
blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of the
acid-base status of the fetus with IUGR, and assessment and treatment of isoimmunization and
thrombocytopenia in the fetus.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 198, 199 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment, Diagnosis
- ANS: C
Amniocentesis would be performed to assess fetal lung maturity in the event of a preterm birth.
Indications for PUBS include prenatal diagnosis or inherited blood disorders, karyotyping of
malformed fetuses, detection of fetal infection, determination of the acid-base status of the fetus with
intrauterine growth restriction, and assessment and treatment of isoimmunization and
thrombocytopenia in the fetus. Typically fetal size is determined by ultrasound during the second
trimester and is not indicated in this scenario. A nonstress test measures the fetal response to fetal
movement in a noncontracting mother.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 202 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation
- ANS: D
An ultrasound is the method of biophysical assessment of the infant that would be performed at this
gestational age. A biophysical profile would be a method of biophysical assessment of fetal well-
being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy.
An MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal).
PTS: 1 DIF: Cognitive Level: Comprehension REF: 194 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning
- ANS: A
Adequate uterine activity necessary for a CST consists of the presence of three contractions in a 10-
minute time frame. If no decelerations are observed in the FHR pattern with the contractions, the
findings are considered to be negative. A positive CST indicates the presence of repetitive later FHR
decelerations. Satisfactory and unsatisfactory are not applicable terms.
PTS: 1 DIF: Cognitive Level: Analysis REF: 206 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment, Diagnosis
- ANS: C
The correct calculation of this woman’s gravidity and parity is 3-1-0-1-0.
Using the GPTAL system explained in question 1, this client’s gravidity and parity information is
calculated as follows:
G: Total number of times the woman has been pregnant (she is pregnant for the third time)
T: Number of pregnancies carried to term (she has had only one pregnancy that resulted in a fetus at
term)
P: Number of pregnancies that resulted in a preterm birth (none)
A: Abortions or miscarriages before the period of viability (she has had one)
L: Number of children born who are currently living (she has no living children)
PTS: 1 DIF: Cognitive Level: Comprehension REF: 211 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis
- ANS: A
Amenorrhea is a presumptive sign of pregnancy. Presumptive signs of pregnancy are those felt by
the woman. A positive pregnancy test, the presence of Chadwick’s sign, and the presence of Hegar’s
sign would all be probable signs of pregnancy.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 213 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
- ANS: B
A primipara is a woman who has completed one pregnancy with a viable fetus. To remember terms,
keep in mind: gravida is a pregnant woman; para comes from parity, meaning a viable fetus; primi
means first; multi means many; and null means none. A primigravida is a woman pregnant for the
first time. A multipara is a woman who has completed two or more pregnancies with a viable fetus.
A nulligravida is a woman who has never been pregnant.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 210 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis
- ANS: A
The operculum protects against bacterial invasion. Leucorrhea is the mucus that forms the
endocervical plug (the operculum). The funic souffle is the sound of blood flowing through the
umbilical vessels. Ballottement is a technique for palpating the fetus.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 216 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment
- ANS: B
Auscultatory changes should be discernible after 20 weeks of gestation. A healthy woman with no
underlying heart disease does not need any therapy. The maternal heart rate increases in the third
trimester, but palpitations may not necessarily occur, let alone double. Auditory changes are
discernible at 20 weeks.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 218 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: C
Estrogen levels increase, causing the upper respiratory tract to become more vascular; thus produces
swelling and congestion in the nose and ears and therefore voice changes and impaired hearing. The
diaphragm is displaced and the volume of blood is increased. However, the main concern is
increased estrogen levels.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 221 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: A
Soon after the fourth month of gestation uterine contractions can be felt through the abdominal wall.
Braxton Hicks contractions are regular and painless and continue throughout the pregnancy.
Although they are not painful, some women complain that they are annoying. Braxton Hicks
contractions usuall ceases with walking or exercise. They can be mistaken for true labor; however,
they do not increase in intensity, frequency, or cause cervical dilation. In addition, they facilitate
uterine blood flow through the intervillous spaces of the placenta and thereby promote oxygen
delivery to the fetus.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 213, 214 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning
- ANS: C
Using Nägele’s rule, November 21, 2010, is the correct expected date of birth. The EDB is
calculated by subtracting 3 months from the first day of the LMP and adding 7 days + 1 year to the
day of the LMP. Therefore, with an LMP of February 14, 2010:
February 14, 2010 – 3 months = November 14, 2009 + 7 days = November 21, 2009 + 1 year =
November 21, 2010
PTS: 1 DIF: Cognitive Level: Knowledge REF: 230 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
- ANS: A
Testing for the antibody to HIV is strongly recommended for all pregnant women. An HIV test is
recommended for all women, regardless of risk factors. The incidence of perinatal transmission from
an HIV-positive mother to her fetus ranges from 25% to 35%. Women who test positive for HIV can
then be treated.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 241 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning
- ANS: D
Signs and symptoms that must be reported include severe vomiting, fever and chills, burning on
urination, diarrhea, abdominal cramping, and vaginal bleeding. These symptoms may be signs of
potential complications of the pregnancy. Nausea with occasional vomiting, fatigue, and urinary
frequency are normal first-trimester complaints. Although they may be worrisome or annoying to the
mother, they usually are not indications of pregnancy problems.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 243 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: B
An increase in the systolic BP of 30 mm Hg or more over the baseline pressure or an increase in the
diastolic BP of 15 mm Hg or more over the baseline pressure is a significant finding, regardless of
the absolute values. A current BP of 130/85 indicates that such increases have occurred in both the
diastolic and systolic pressures. A slight increase in BP of 126/85 does not meet the criteria for
concern. Although the baseline BP is worrisome (an absolute systolic BP of 140 mm Hg or higher or
a diastolic BP of 90 mm Hg or higher suggests hypertension), the subsequent pressures have
decreased, not increased. The BP of 110/60 is within normal limits for both values and is not a
concern.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 243 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis
- ANS: B
Pelvic rock exercises may help stretch and strengthen the abdominal and lower back muscles and
relieve low back pain. Kegel exercises increase the tone of the pelvic area, not the back. A softer
mattress may not provide the support needed to maintain proper alignment of the spine and may
contribute to back pain. Stretching and other exercises to relieve back pain should be performed
several times a day.
PTS: 1 DIF: Cognitive Level: Application REF: 249, 256 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
- ANS: D
Women who are HIV positive are discouraged from breastfeeding. Although hepatitis B antigen has
not been shown to be transmitted through breast milk, as an added precaution infants born to
HBsAg-positive women should receive the hepatitis B vaccine and immune globulin immediately
after birth. Everted nipples are functional for breastfeeding. Newly diagnosed breast cancer would be
a contraindication to breastfeeding.
Needs for energy, protein, calcium, iodine, zinc, the B vitamins, and vitamin C remain greater than
nonpregnant needs.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 285 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: C
This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant
products. Because vitamin B 12 is found in foods of animal origin, this diet is deficient in vitamin B 12.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 293 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment
- ANS: D
A healthy diet before conception is the best way to ensure that adequate nutrients are available for
the developing fetus. A woman’s folate or folic acid intake is of particular concern in the
periconception period. Neural tube defects are more common in infants of women with a poor folic
acid intake. Depending on the type of contraception used, discontinuing all contraception may not be
an accurate statement. Losing weight is not appropriate advice. Depending on the type of medication
the woman is taking, continuing its use may not be an accurate statement.
PTS: 1 DIF: Cognitive Level: Application REF: 284 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning
- ANS: B
Both normal-weight and underweight women with inadequate weight gain have an increased risk of
giving birth to an infant with intrauterine growth restriction. Spina bifida, diabetes mellitus, and
Down syndrome are not associated with inadequate maternal weight gain.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 277 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
- ANS: A
Good protein sources such as meat, milk, eggs, and cheese have a lot of calcium and iron. Most
women already eat a high-protein diet and do not need to increase their intake. Protein is sufficiently
important that specific servings of meat and dairy are recommended. High-protein supplements are
not recommended because they have been associated with an increased incidence of preterm births.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 279 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: A
Insulin needs are reduced in the first trimester because of increased insulin production by the
pancreas and increased peripheral sensitivity to insulin. “Insulin dosage will likely need to be
increased during the second and third trimesters,” “Episodes of hypoglycemia are more likely to
occur during the first 3 months,” and “Insulin needs should return to normal within 7 to 10 days after
birth if I am bottle-feeding” are accurate statements and signify that the woman has understood the
teachings regarding control of her diabetes during pregnancy.
PTS: 1 DIF: Cognitive Level: Application REF: 297 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Evaluation
- ANS: D
Women with excellent glucose control and no blood vessel disease should have good pregnancy
outcomes.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 298 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning
- ANS: A
Target glucose levels during a fasting period are 60 to 90 mg/dl. A glucose level of 90 to 120 mg/dl
is consistent with expected levels at bedtime. A glucose level of 120 to 150 mg/dl is considered
elevated for a fasting glucose level. A glucose level of 150 to 180 mg/dl is considered elevated for a
fasting glucose level and indicates poor glycemic control.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 301 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
- ANS: B
Type 2 often goes undiagnosed because hyperglycemia develops gradually and often is not severe.
Type 2, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of
glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do
not go back and forth between types 1 and 2 diabetes.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 296 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment
- ANS: C
Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin
never crosses the placenta; the fetus starts making its own around the tenth week. As a result of
normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia
(low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 297 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment
- ANS: A
Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times
more often in diabetic pregnancies. Infections are more common and more serious in pregnant
women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant
effects on fetal well-being.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 299 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: B
Before a treatment plan is developed or goals for the outcome of care are outlined, this client must
come to an understanding of diabetes and the potential effects on her pregnancy. She appears to have
greater concern for changes to her social life than adoption of a new self-care regimen. Risk for
injury to the fetus related to either placental insufficiency or birth trauma may come much later in
the pregnancy. At this time the client is having difficulty acknowledging the adjustments that she
needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on
insulin. Insulin requirements increase with gestation. The importance of glycemic control must be
part of health teaching for this client. However, she has not yet acknowledged that changes to her
lifestyle need to be made and may not participate in the plan of care until understanding takes place.
Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days
sets things right in most cases. Although 70% of pregnant women experience nausea and vomiting,
fewer than 1% proceed to this severe level. IV administration may be used at first to restore fluid
levels, but they are seldom needed for very long. Women suffering from this condition want
sympathy, because some authorities believe that difficult relationships with mothers and/or partners
may be the cause.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 349 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment
- ANS: A
Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell
count. Rupture of the appendix is two to three times more likely in pregnant women. Surgery to
remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy
predisposes a woman to ovarian problems.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 368 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment
- ANS: C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value
of 3+ should alert the nurse that additional testing or assessment should be made. Generally
hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or 15 mm
Hg diastolic pressure. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1
week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore the
presence of edema is no longer considered diagnostic of preeclampsia.
PTS: 1 DIF: Cognitive Level: Analysis REF: 335, 336 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis
- ANS: D
If a client becomes eclamptic, the nurse should stay with him or her and call for help.
Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should
attempt to keep the airway patent by turning the client’s head to the side to prevent aspiration. Once
the seizure has ended, it may be necessary to suction the client’s mouth. Oxygen would be
administered after the convulsion has ended.
PTS: 1 DIF: Cognitive Level: Application REF: 347 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation
- ANS: C
The client is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be
discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be
administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe
preeclampsia. Typically it is administered for a systolic BP over 160 mm Hg or a diastolic BP over
110 mm Hg.
PTS: 1 DIF: Cognitive Level: Application REF: 340 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation
- ANS: A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia.
Typically it is administered for a systolic BP over 160 mm Hg or a diastolic BP over 110 mm Hg. An
additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system
irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam
sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote
for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of
magnesium toxicity.
PTS: 1 DIF: Cognitive Level: Analysis REF: 346 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
- ANS: A
Risk for injury to the fetus related to uteroplacental insufficiency is the most appropriate nursing
diagnosis for this client scenario. Other diagnoses include risk to fetus related to preterm birth and
abruptio placentae. Eclampsia is a medical, not a nursing, diagnosis. There would be a risk for
excess, not deficient, fluid volume related to increased sodium retention. There would be a risk for
decreased, not increased, cardiac output related to the use of antihypertensive drugs.
PTS: 1 DIF: Cognitive Level: Application REF: 336 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis
- ANS: C
The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify
because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is
greatly increased and so is perinatal mortality.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 338 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Diagnosis, Planning
- ANS: B
This is an accurate statement. -human chorionic gonadotropin (hCG) levels will be drawn for 1
year to ensure that the mole is completely gone. There is an increased chance of developing
choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a “zero” hCG
level. If the woman were to become pregnant, it may obscure the presence of the potentially
carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a
hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic
cells are not present. Any contraceptive method except an intrauterine device is acceptable.
PTS: 1 DIF: Cognitive Level: Application REF: 359 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning, Implementation
- ANS: C
Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman
whose ectopic pregnancy is unruptured and less than 4 cm in diameter. Methotrexate is not indicated
or recommended as a treatment option for complete hydatidiform mole, missed abortion, and
abruptio placentae.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 357 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning
