Chapter 11: Caring for the Woman Experiencing Complications During Pregnancy Nursing School Test Banks

Chapter 11: Caring for the Woman Experiencing Complications During Pregnancy

MULTIPLE CHOICE

1. A woman presents to the perinatal clinic with abdominal pain. She has missed one period and, following a transvaginal ultrasound, pregnancy is confirmed. However, implantation has occurred in the right fallopian tube. The ectopic mass is 3 cm and has not ruptured. The nurse prepares the patient for which therapy?
A. Laparoscopic salpingostomy
B. Methotrexate
C. Partial salpingectomy
D. Salpingectomy by laparotomy
ANS: B
Methotrexate, a chemotherapeutic drug and folic acid inhibitor that stops cell production and destroys remaining trophoblastic tissue, is used in the management of uncomplicated, non-life-threatening ectopic pregnancies. Patients are considered to be eligible for methotrexate therapy if the ectopic mass is unruptured and measures 4 cm or less on ultrasound examination. The other options would not be needed.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

2. The prenatal clinic nurse assesses a woman at 15 weeks gestation. The patients blood pressure, measured twice at intervals 1 hour apart with a cuff that fits appropriately, is 146/96 mm Hg. The nurse understands the patient has which condition?
A. Chronic hypertension
B. Gestational hypertension
C. Preeclampsia
D. Transient hypertension
ANS: A
Chronic hypertension is defined as hypertension that is present and observable prior to pregnancy, or hypertension that is diagnosed before the 20th week of gestation. Hypertension is defined as a blood pressure greater than 140/90 mm Hg. Hypertension for which a diagnosis is confirmed for the first time during pregnancy and that persists beyond the 84th day postpartum is also classified as chronic hypertension. Gestational hypertension occurs after 28 weeks without proteinuria and is a temporary diagnosis used until more diagnostic testing can be accomplished. Preeclampsia is an increased blood pressure seen after 20 weeks gestation accompanied by proteinuria. Transient hypertension describes women who develop gestational hypertension but have no preeclampsia and whose blood pressure returns to normal within 12 weeks postpartum. This diagnosis is used only after pregnancy.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

3. The perinatal nurse is assessing a woman who is at 35 weeks gestation in her first pregnancy. She is worried about having her baby too soon, and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats/minute. A vaginal examination performed by the health-care provider reveals no cervical changes since her last examination. Ultrasound examination reveals the presence of V-shaped cervical funneling. Which action by the nurse is most appropriate?
A. Educate the woman on benefits of corticosteroids.
B. Facilitate admission to the high-risk OB unit.
C. Prepare to administer a dose of magnesium sulfate.
D. Reassure the woman that she is not in preterm labor.
ANS: D
Preterm labor is defined as regular uterine contractions and cervical changes before the end of the 37th week of gestation. Many patients present with preterm contractions but only those who demonstrate changes in the cervix are diagnosed with preterm labor. Because this woman has no demonstrated cervical changes, she does not have the diagnosis. Also reassuring is the infrequency of her contractions; a defining characteristic of preterm labor is persistent uterine contractions (4 every 20 minutes or 8 per hour). Another reassuring finding is the presence of V-shaped cervical funneling ; a change to U-shaped cervical funneling in a woman with a shortened cervix is associated with preterm labor in high-risk women with a prior spontaneous preterm birth. The woman does not require corticosteroids or magnesium sulfate or admission to the high-risk OB unit.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

4. The perinatal nurse is caring for a woman at 26 weeks gestation who has a history of hypertension that has been well controlled. Today she presents with a blood pressure of 156/102 mm Hg and she has 2+ protein on urine dipstick. Which initial action by the nurse is most appropriate?
A. Arrange admission to the high-risk OB unit.
B. Instruct the woman on strict bedrest.
C. Obtain a clean-catch urine sample.
D. Prepare to administer IV anti-hypertensives.
ANS: C
Preeclampsia can occur in a woman who has chronic hypertension. This woman has the characteristics of hypertension after a period of good control and proteinuria of at least 2+ on dipstick (100 mg/dL). The nurse needs to ensure protein levels are assessed in two samples at least 4 hours apart and ensure the woman has no signs of a urinary tract infection, as protein can occur in a sample of infected urine. The nurse should obtain a clean-catch urine sample to send to the laboratory for analysis. Asymptomatic UTI can occur in up to 11% of pregnant women, so assessing for signs and symptoms may not be accurate. The woman does not need admission to the high-risk OB unit, strict bedrest, or IV anti-hypertensives at this point.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

5. A 22-year-old woman presents to the emergency department with abdominal pain and
vaginal bleeding. Her blood pressure is 90/58 mm Hg, her pulse is 120 beats/minute, and she complains of dizziness. Which action by the nurse takes priority?
A. Assess the woman for sexually transmitted infections.
B. Collect a urine sample for pregnancy testing.
C. Obtain informed consent for a salpingectomy.
D. Start two large-bore IVs for fluid replacement.
ANS: D
This patient has both signs (hypotension, tachycardia) and symptoms (complaints of dizziness) of acute volume loss. The nurse should consider a ruptured ectopic pregnancy as a possible problem in this patient and assess her for other manifestations and risk factors. However, the priority is starting large-bore IV lines for fluid resuscitation. The nurse may need to obtain informed consent for an operative procedure once a definitive diagnosis is made.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

6. A woman in her second trimester of pregnancy presents to the perinatal clinic with complaints of scant vaginal bleeding, abdominal pain, and shoulder pain. What action should the nurse perform first?
A. Assess her for a history of preterm labor.
B. Obtain a blood sample for a b-hCG test.
C. Prepare the woman for a pelvic exam.
D. Request an order for methotrexate (Rheumatrex).
ANS: B
This woman is displaying symptoms of a possible ruptured ectopic pregnancy (vaginal bleeding, abdominal pain, shoulder pain). Shoulder pain can occur from nerve irritation due to the presence of blood in the pelvic cavity. A b-hCG test finding will be lower than expected for the gestational age. The woman will most likely need a pelvic exam. However, to facilitate a rapid diagnosis, the nurse should first obtain and send a blood sample for b-hCG test. The nurse can then assess the woman for risk factors for ectopic pregnancy. However, preterm labor is not a risk factor. Methotrexate is used for uncomplicated, non-life-threatening ectopic pregnancies. It would not be indicated in this patient because she has manifestations of rupture.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

7. A nurse is caring for a patient who has been diagnosed with an incomplete molar pregnancy. Which action by the nurse is most appropriate?
A. Advise the woman that she can try to get pregnant in 3 months.
B. Arrange a consultation with a radiation oncology nurse.
C. Facilitate screening for systemic lupus erythematosus (SLE).
D. Give the patient information on perinatal loss support groups.
ANS: D
Gestational trophoblastic disease (GTD) is a disease characterized by an abnormal placental development that results in the production of fluid-filled grapelike clusters (instead of normal placental tissue) and a vast proliferation of trophoblastic tissue. GTD includes the diagnosis of hydatidiform mole (molar pregnancy). Complete moles have a proliferation of trophoblastic tissue, but no fetal parts. An incomplete mole is associated with a coexistent fetus that is genetically abnormal and usually only survives a few weeks before being spontaneously aborted. Support groups for grieving parents are an important community resource, and the nurse should ensure that the woman has information on local organizations. Management includes emptying the uterus of its contents with strict follow-up. Women should not become pregnant for at least a year afterward. Incomplete moles are almost always benign, so a consultation for a radiation oncology nurse is most likely not needed. Screening for SLE is done in women who have habitual abortions.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

8. A nurse is assessing a 52-year-old primigravida woman who presents complaining of moderate dark-brown vaginal bleeding. On physical exam, her uterus is large for dates. Which action by the nurse is most appropriate?
A. Assess the womans diet for folic acid intake.
B. Facilitate an ultrasound examination.
C. Instruct the woman on a fetal kick count.
D. Prepare the woman for pelvic cultures.
ANS: B
The incidence of gestational trophoblastic disease (GTD), including hydatidiform mole, increases in women of advanced age (especially over 50). Dark-brown vaginal bleeding is one symptom of this condition, and the nurse should be cognizant of its possibility. Because hydatidiform mole is diagnosed with ultrasound, the nurse should facilitate this testing. A diet low in folic acid is a risk factor, but the nurse should delay assessing for risk factors until after he or she has facilitated the ultrasound. Because molar pregnancies are either associated with no fetus or one that is generally spontaneously aborted, instructing the woman on fetal kick counts is not appropriate. The patient does not need pelvic cultures for this condition.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

9. A woman who recently had a miscarriage is in the clinic for follow-up. She sees the diagnosis spontaneous abortion on her chart and becomes visibly upset, stating, I did not have an abortion! Which response by the nurse is best?
A. Dont be upset; that is just a medical term used commonly.
B. I can come back and talk to you when you are not so upset.
C. I see you are upset. Does it help to know this means miscarriage?
D. No one is accusing you of having an abortion.
ANS: C
The term spontaneous abortion is the medical term for miscarriage before 20 weeks gestation. Medical terms are often confusing to laypeople, and it is the nurses duty to inform patients of their meaning. Nurses should also be aware that the term abortion is politically and emotionally laden, so it should not be surprising that an uninformed layperson might become upset at its use. The nurse should acknowledge the womans feelings and explain the term. Telling the woman not to be upset is paternalistic and does nothing to educate her. Offering to come back later would be a useful option after the nurse has acknowledged the womans feelings and discovered that she does not want to talk right now; otherwise, this statement might seem like rejection. Stating that no one is accusing the woman of having an abortion is defensive.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

10. A student in a perinatal clinic asks the clinic nurse what an incomplete abortion is. Which response by the nurse is best?
A. Complete loss of all products of conception before 20 weeks gestation
B. Fetal death before 20 weeks with retention of all products of conception
C. Loss of some, but not all, products of conception before 20 weeks
D. When the patient initiates an abortion, but then stops the procedure
ANS: C
An incomplete abortion is the expulsion of some, but not all, products of conception prior to 20 weeks. Fetal death with retention of all products of conception prior to 20 weeks is called a missed abortion. Complete expulsion of all products of conception before 20 weeks is a complete spontaneous abortion. If a patient chooses to have an abortion, it is termed an elective abortion.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

11. The nurse finds a woman who has recently suffered her third complete abortion crying and saying Why me? What did I do to deserve being punished like this? Which response by the nurse is best?
A. Ask the woman if she uses illicit drugs or drinks alcohol during pregnancy.
B. Explain that most miscarriages are related to genetic abnormalities.
C. Offer to call a clergy member or social worker to visit with the woman.
D. Reassure the woman that she is not being punished.
ANS: C
Women (and their partners) frequently need support with any perinatal loss. The best option here would be for the nurse to offer to call a clergy member or social worker to visit and offer assistance. Asking if the woman uses illicit drugs or drinks alcohol sounds as if the nurse is trying to blame the woman for the miscarriages. Simply explaining that most spontaneous abortions involve a fetus with chromosomal abnormalities does nothing to address the womans feelings, although it should be part of a comprehensive plan of action. Simply reassuring the woman that she is not being punished sounds paternalistic.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Easy

PTS: 1

12. A nurse is assessing a woman in the perinatal clinical with diagnosed cervical insufficiency. The woman is in her 18th week of a viable pregnancy. Which action by the nurse is most appropriate?
A. Assist with obtaining informed consent for a cerclage.
B. Draw blood to assess the maternal Rh status.
C. Facilitate a transvaginal and abdominal ultrasound.
D. Refer the woman to a perinatal grief specialist.
ANS: A
Because the woman has diagnosed cervical insufficiency, a cerclage is appropriate therapy. This purse-string suture closes the cervix so the uterus can contain the pregnancy. It is usually removed in the 37th week to allow for vaginal delivery. Because it is an invasive procedure, informed consent is required. The other options are not necessary in this situation, although if the woman has unresolved grief following prior spontaneous abortions, a referral would be appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

13. A woman is being dismissed after undergoing placement of a cerclage. The woman is married with a husband who travels frequently and the couple has two other children. Which action by the nurse is most helpful?
A. Arrange for the visiting nurse to administer IV antibiotics.
B. Educate the woman on the need for strict bedrest.
C. Enlist the services of a social worker to help her plan care for her other children.
D. Teach the woman about the side effects of metachlopramide (Reglan).
ANS: C
After cerclage placement, bedrest is necessary. It is often difficult for a woman to maintain bedrest, especially if she has other children. A social worker can be helpful in assisting the woman to make contact with support organizations and in developing a working plan to care for the other children and household obligations. IV antibiotics are not routinely needed. Education on bedrest is important, but without acknowledging and acting on the profound disruptions that it can cause for a family, education alone is likely to be unsuccessful in promoting bedrest. Metachlopramide is used for nausea.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

14. The nurse manager in a perinatal clinic is reviewing research related to care of patients with cervical insufficiency and preterm birth. What practice change might result from this review of the literature?
A. Administering fewer doses of Rho(D) immune globulin (RhoGAM)
B. Decreased utilization of cerclage placement in women with preterm labor
C. Measuring serial cervical lengths in all women pregnant with singletons
D. Providing betamethasone (Celestone) as long-term therapy
ANS: B
According to a meta-analysis by Berghella and Mackeen (2011), singleton gestations in women with prior preterm birth might be monitored safely with transvaginal ultrasound cervical length screening, and they suggested that cerclage placement be reserved for the minority of women who actually develop a short cervical length. Administration of RhoGAM is not related. Only women with a history of preterm birth need cervical length measurement according to current practice. Celestone is not used for long-term therapy.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Planning
Difficulty: Difficult

PTS: 1

15. A woman is hospitalized with hyperemesis gravidarum. Which other member of the health-care team should the nurse ensure is involved in this patients care as a priority?
A. Chaplain
B. Diabetic educator
C. Mental health nurse practitioner
D. Registered dietician
ANS: D
Although all members of the health-care team have important roles to play and may be needed in the care of this patient, the dietician is the priority. Patients with hyperemesis gravidarum have extreme nausea and vomiting unrelated to other causes. They demonstrate weight loss and measures of starvation such as ketosis. Serious complications arise if the woman cannot maintain her weight despite antiemetics. The dietician will be helpful in assisting the woman to plan appropriate meals and snacks or, if the woman needs enteral or parenteral feedings, in providing nutritional information to guide therapy.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

16. A nurse has admitted a patient with hyperemesis gravidarum and is reviewing the physicians orders. Which order should the nurse question?
A. Betamethasone (Celestone) 100 mg IV every 8 hours
B. Dimenhydrinate (Dramamine) 75 mg rectally every 46 hours
C. Metoclopramide (Reglan) 10 mg IV every 8 hours
D. Promethazine (Phenergan) 25 mg IV every 4 hours
ANS: A
Dimenhydrinate, metoclopramide, promethazine, and pyridoxine are all used to treat nausea and vomiting of pregnancy. Betamethasone is used to decrease the chance of respiratory distress syndrome in premature infants. It is given in 2 doses, 12 hours apart, at a dose of 12 mg.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

17. A pregnant patient in the second trimester is in the emergency department after a motor vehicle crash. She has a severe laceration of her arm resulting in a large blood loss. Which assessment should the nurse perform first?
A. Blood pressure
B. Fetal heart tones
C. Pulse
D. Respiratory rate
ANS: C
Because a womans blood volume can increase dramatically during pregnancy, blood pressure is an unreliable indicator of a volume deficit. Maternal pulse and fetal heart rate are much more accurate indicators. Because the priority in care of the pregnant trauma patient is care of the mother, the nurse should assess the mothers blood pressure first.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

18. A nurse is teaching a woman pregnant in the second trimester who has been diagnosed with a partial placenta previa. Which information is most important to document?
A. Patient and partner show no anxiety or helplessness and were given educational support material.
B. Patient instructed that bleeding may occur as placenta totally covers the cervical os.
C. Patient instructed to tell all health-care providers that vaginal exams are prohibited.
D. Patient received information about placenta previa and understood it well.
ANS: C
If the patient needs care from another health-care provider, she must tell him or her that due to her placenta previa, all vaginal exams are prohibited. This is an important safety measure that must be taught and clearly documented. Assessing (and documenting) the psychosocial status of the patient and partner are important too, but safety takes priority. A partial placental previa only partly covers the cervical os. The statement that the patient received information and understood it well is vague and does not constitute an example of acceptable charting.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

19. A nurse has admitted a woman pregnant in her third trimester with moderate vaginal bleeding and severe abdominal pain. After assessing maternal vital signs, obtaining the fetal heart rate, and starting an IV line, which action should the nurse do next?
A. Administer betamethasone (Celestone) just prior to delivery.
B. Discuss pros and cons of continuous fetal monitoring.
C. Facilitate laboratory work, including blood type and screen.
D. Obtain informed consent for emergent delivery.
ANS: C
Women who present with third-trimester vaginal bleeding should be examined carefully for placenta previa or abruptio placentae. Bleeding accompanied by abdominal pain is the classic sign of placental abruption. Care includes obtaining maternal vital signs, assessing fetal heart rate, and starting an IV for fluid resuscitation or transfusion if needed. Blood work should be obtained for CBC, type and screen, coagulation studies, and a Kleihauer Betke determination, Betamethasone is given if delivery is not imminent. Continuous electronic fetal monitoring is the standard of care, and although the nurse should educate the patient on its use, this discussion does not take priority over obtaining diagnostic laboratory studies. An emergent delivery is a possible (not certain) outcome, but obtaining consent does not take priority over the diagnostic blood work.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

20. A woman with a history of previous abruptio placentae with fetal demise is being seen in the
perinatal clinic. She is now pregnant again in her early second trimester. She tells the nurse she is a Jehovahs Witness and she wants her chart to reflect her refusal to accept blood products if she hemorrhages again. Which action by the nurse is best?
A. Ask the woman to consider an exception in order to save her babys life if needed.
B. Document the information on the chart and inform the health-care provider.
C. Encourage the woman and provider to discuss appropriate delivery sites.
D. Tell the woman a court can order the transfusion to save the baby.
ANS: C
Jehovahs Witnesses do not accept blood products or their derivatives as part of their medical care. Because this woman is at high risk for a complicated pregnancy (another abruptio placentae) and hemorrhage, she should be advised to deliver in a tertiary care center that is prepared to manage catastrophic hemorrhage. The nurse should facilitate this discussion as part of providing holistic care. Asking the woman to reconsider (and go against her religious beliefs) is disrespectful. The nurse should document the information and inform the care provider, but this action in itself is incomplete. Telling the woman that a court can order her to have transfusions, although a true statement, is likely to be perceived as threatening and disrespectful, and certainly does not allow the nurse to provide care in a holistic manner.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

21. A nurse wants to conduct a community education session for women at high risk of preterm birth. Which teaching site would best meet this objective?
A. After services at a predominantly African American church
B. At the local Asian and African markets during a weekday
C. In the lobby of several OB-GYN clinics in the suburbs
D. Near the food court at the local shopping mall
ANS: A
The March of Dimes reports that the ethnic group with the highest rate of preterm births is African American women, at 18.4%. Although teaching all women about preterm births is an important goal, to reach the group with the highest risk, the nurse should plan to teach at a predominantly African American church over the other sites.

Cognitive Level: Analysis
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

22. A woman who is in her third trimester and is at risk for preterm birth calls the clinic to get the results of her fetal fibronectin test (fFN). The nurse sees the result is negative. Which advice to the patient is most appropriate?
A. Come to the perinatal clinic for a screening ultrasound.
B. Continue the current management plan as directed.
C. Go to the hospital immediately for imminent delivery.
D. Plan to continue taking betamethasone (Celestone) for 1 week.
ANS: B
A negative fFN test indicates that the chance of a woman giving birth in the next week is approximately 1%, so she should continue her management plan already in place. There is no need for a screening ultrasound or hospitalization. Betamethasone is a corticosteroid shown to improve outcomes in premature birth. Because this woman is at low risk of delivery within the next week, betamethasone is not indicated.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

23. A woman who is 36 weeks pregnant presents to the perinatal clinic with complaints of backache, pelvic fullness, and uterine contractions. Which action by the nurse is most appropriate?
A. Arrange admission to the hospital.
B. Obtain a clean-catch, midstream urine sample.
C. Obtain blood for a type and screen.
D. Prepare to administer a tocolytic agent.
ANS: B
Infection is a predisposing factor for preterm labor, so the nurse would be wise to collect a urine sample, which may be obtained via clean-catch or catheterized specimen. Arranging admission to the hospital is premature. Also, there is no indication that the patient will need blood imminently, and tocolytic agents to stop preterm labor are not used after the 34th week of gestation.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

24. A woman at 32 weeks gestation is admitted to the high-risk OB unit with a diagnosis of preterm labor. On assessment the nurse finds the following: blood pressure, 182/96 mm Hg; pulse, 106 beats/minute; respirations, 16 breaths/minute; regular uterine contractions of 5 in 10 minutes; and fetal heart rate of 145 beats/minute. She is dilated to 8 cm. Which action by the nurse is best?
A. Administer the ordered dose of betamethasone (Celestone).
B. Call for an immediate electrocardiogram (EKG).
C. Document the findings and prepare for emergent delivery.
D. Prepare to administer magnesium sulfate (Sulfamag).
ANS: A
The administration of antenatal corticosteroids (betamethasone) is the most beneficial intervention for improvement of neonatal outcomes among women who give birth preterm. A single course of corticosteroids is recommended for pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days. Although the woman is mildly tachycardic, there is no need for an EKG without further information. There is no indication that delivery is imminent. Magnesium sulfate is a tocolytic drug used to stop labor, but it is contraindicated in women with advanced cervical dilation.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

25. A woman is admitted to the high-risk OB unit with the diagnosis of preterm labor. Orders include bedrest with continuous fetal monitoring, administration of magnesium sulfate (Sulfamag) and betamethasone (Celestone), and laboratory work. In reviewing the patients record, the nurse notes a history of hypertension that is well controlled with nifedipine (Procardia) and diet-controlled diabetes mellitus type 2. Which action by the nurse is best?
A. Assist the woman to choose appropriate food items from the menu.
B. Call the physician to question the orders and document the conversation.
C. Order a pressure-relieving mattress overlay and perform a skin assessment.
D. Prepare to give the magnesium sulfate and betamethasone as ordered.
ANS: B
The combination of nifedipine and magnesium sulfate can cause sudden cardiac death. The nurse should contact the health-care provider to question the orders. The nurse should also document all aspects of this communication clearly. The woman may or may not need assistance in choosing food items appropriate for her diabetes. All patients need a full skin assessment and, depending on how long bedrest is anticipated, a pressure-relieving mattress overlay might be appropriate. The nurse should not give the medications without further clarification.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

26. A woman who is 28 weeks pregnant is admitted to the high-risk OB unit with preterm premature rupture of the membranes. Four hours after admission, the nurse notes the following: temperature: 38.5C (101.5F), maternal pulse: 122 beats/minute, and white blood cell count: 23,000 mm3. Which action by the nurse takes priority?
A. Document the findings and notify the health-care provider.
B. Facilitate fern testing or Nitrazine testing on vaginal fluid.
C. Prepare to administer a prn dose of acetaminophen (Tylenol).
D. Reassure the woman that these are expected findings.
ANS: A
Delivery for a woman with premature rupture of membranes should be accomplished immediately for signs of maternal infection, advanced labor, vaginal bleeding, or nonreassuring fetal signs. This patients vital signs and WBC indicate infection. The nurse should document the findings and notify the health-care provider so that arrangements can proceed. Fern testing or Nitrazine testing is done to help diagnose rupture of the membranes and is not needed at this time. Giving acetaminophen at this time is not a priority and may be contraindicated if the woman needs to be placed on NPO status.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

27. A new nurse is caring for a woman previously diagnosed with preeclampsia who was admitted to the high-risk OB unit after suffering a seizure in the perinatal clinic. The new nurse is preparing to administer a dose of magnesium sulfate (Sulfamag). Which action by the nurse warrants intervention by the unit manager?
A. Explains to the patient that her vital signs and EKG will be monitored frequently
B. Piggybacks the Sulfamag into a main line using an infusion pump
C. Places 10% calcium gluconate in a secure location in the patients room
D. Runs the Sulfamag as the main IV line through an infusion pump
ANS: D
Magnesium sulfate should be infused on an infusion pump piggybacked into the main line, not as the primary IV line. The other actions are appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

28. A pregnant patient is brought to the emergency department after a roll-over motor vehicle crash. After assessing and stabilizing the patients airway, breathing, and circulation, which of the following actions should the nurse perform next?
A. Assess the woman for further injuries.
B. Attach continuous fetal monitoring leads.
C. Determine the date of the patients last tetanus booster.
D. Prepare to transfer the woman to the delivery suite.
ANS: B
Maternal trauma accounts for about 50% of fetal deaths. Seemingly minor injuries to the woman may cause serious injury or death to the fetus. Because the fetal heart rate is one of the first signs to change in fetal distress, all pregnant trauma patients need continuous fetal monitoring. Assessing the woman for further injuries and determining the date of the womans last tetanus booster are both appropriate actions; however, they do not take priority over fetal monitoring. The woman may or may not need to be transferred to the delivery suite.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

29. A nurse is caring for a woman receiving continuous electronic fetal monitoring. Which action by the nurse is most important?
A. Educate the woman and her partner about the importance of electronic fetal monitoring.
B. Ensure clearly readable monitoring strips are placed in the patients chart per protocol.
C. Offer diversionary activities for the woman and partner while they are in the hospital.
D. Restrict visitors in order to decrease the chance of being exposed to infectious illness.
ANS: B
Fetal monitoring strips (along with other documentation) can show that the standard of care was met if questions arise. An important nursing responsibility in caring for women with electronic fetal monitoring is to ensure strips are clear enough to be interpreted and strips are placed in the patients chart according to facility policy. Education and diversionary activities are important actions, but do not take priority over this legal responsibility. Restricting visitors may or may not be appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

30. A perinatal nurse has developed a birth plan with a woman who is in her third trimester and has a physical disability. Which action by the nurse would be best for this patient?
A. Arrange for a social work home visit after the woman gives birth and goes home.
B. Consult with the OB clinical nurse specialist to plan for the womans birth.
C. Notify the unit manager about the upcoming delivery of a woman with a disability.
D. Prepare a written birth plan document and ensure the woman has a copy to take with her.
ANS: B
Consulting with the clinical nurse specialist (or the unit manager) allows for special needs to be documented and prepared for. There is no indication that the woman needs a social worker to visit her at home after the birth, but home health-care options should be investigated and planned ahead of time, if needed or desired. Simply telling the unit manager about this womans upcoming birth will not allow for her needs to be anticipated and planned for. Although a written copy of a birth plan is good to facilitate communication, this alone will not allow for pre-planning for any special needs.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

31. A student nurse asks the perinatal nurse why teenagers might be vulnerable to intimate partner violence. Which answer by the nurse is best?
A. Because teens are dependent on others for their everyday living needs.
B. Being younger and smaller makes them more apt to be physically abused.
C. Pregnant teens are often addicted to drugs and alcohol, or are prostitutes.
D. So many teens make bad choices, and choosing abusive men is one of them.
ANS: A
Teenagers, especially the younger ones, are very dependent on others for the basics of their everyday lives, and this vulnerability often makes it difficult to leave an abusive situation in which they depend on their abusers. The other options are inaccurate, dismissive, and stereotypical.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

32. The nurse has admitted a patient to the high-risk OB unit with preterm premature rupture of the membranes. After obtaining maternal vital signs and the fetal heart rate, which action should the nurse do next?
A. Assess for coping skills in the woman and her partner.
B. Attach the woman to continuous electronic fetal monitoring.
C. Consult social work for diversionary activities to enhance bedrest.
D. Prepare to administer antibiotics for presumed chorioamnionitis.
ANS: B
Management of premature rupture of the membranes consists of prolonged maternal and fetal monitoring and modified bedrest. The nurse should attach the fetal monitor to the patient. In high-risk pregnancies, coping skills are often exhausted, and the nurse would do well to assess the state of coping in this patient, but this does not take priority. Providing diversionary activities would help enhance the bedrest experience, but, again, this does not take priority. There is no indication that the woman has chorioamnionitis, although it is a common cause of premature rupture of membranes. If diagnostic data indicate an infection, an antibiotic would be appropriate at that time.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Intervention
Difficulty: Moderate

PTS: 1

33. A patient in the high-risk OB unit has suffered a seizure and is now postictal. She is on oxygen at 2L/minute. Which assessment by the nurse warrants immediate intervention?
A. Fetal heart rate is 98 beats/minute on electronic fetal monitor strip.
B. Maternal oxygen saturation is 94% by pulse oximetry.
C. Mother is sleeping soundly and is difficult to arouse.
D. Mothers respiratory rate is 12 breaths/minute.
ANS: A
After a seizure, all fetuses must be checked and accounted for. Fetal heart rate may show variability or bradycardia. A fetal heart rate of 98 is bradycardic, and the nurse should intervene immediately. Oxygen saturation of 94% is normal, a postictal patient will be drowsy and difficult to arouse, and a respiratory rate of 12 breaths/minute is normal.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

34. A pregnant patient with a long-standing history of cardiovascular disease is admitted to the high-risk OB unit. The patient will have internal continuous electronic fetal monitoring until delivery. Which action by the nurse takes priority?
A. Assess the womans vital signs every hour until delivery.
B. Consult with the physician about prophylactic antibiotics.
C. Educate the woman and partner about this modality.
D. Prepare an infusion of magnesium sulfate (Sulfamag).
ANS: B
Internal electronic fetal monitoring is an invasive procedure that carries the risk of infection. Because the patient has a history of cardiac disease, the nurse should consult with the physician about antibiotics in case the woman is at risk for endocarditis. If the patient is stable and not in labor, hourly vital signs are not needed. Education is always an important responsibility, but patient safety and infection control are higher priorities. There is no indication that the woman needs magnesium sulfate.

Objective: 11-5
Reference:
Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

35. A woman pregnant with triplets is a patient in the high-risk OB unit. Which action by the nurse is most appropriate?
A. Document serial, individual fetal monitor strips.
B. Label the monitor lines in descending fetal order.
C. Monitor the fetuses simultaneously with a triplet monitor.
D. Obtain fetal monitor strips in presenting order.
ANS: C
Fetal monitoring of multiples may be difficult, but triplet monitors are available and should be used, if possible, for triplets. This is preferable to obtaining serial, individual tracings. The fetuses are labeled in ascending order, with the presenting fetus labeled A. It is not necessary to monitor the fetuses in presenting order so long as they are clearly labeled.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

36. A nurse is caring for a pregnant woman admitted to the high-risk OB unit. Which finding indicates to the nurse that outcomes for a priority nursing diagnosis have been met?
A. Patient can list community resources available for her after childbirth.
B. Patient describes skills she and partner use for dealing with stress.
C. Patient states that with next pregnancy, she will obtain consistent prenatal care.
D. Patients blood pressure is 128/62 mm Hg without orthostatic changes.
ANS: D
All options show that outcomes for important nursing diagnoses for a high-risk pregnancy have been met. However, physical needs take priority over psychosocial needs, so describing community resources and coping skills are not the most important. Prenatal care is important to help prevent adverse outcomes, but the patient is describing actions she intends to take for a subsequent, not current, pregnancy. For physical needs, airway, breathing, and circulation take priority. A stable blood pressure without orthostatic changes demonstrates hemodynamic stability and shows that outcomes for the diagnosis of risk for deficient fluid volume have been met.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Evaluation
Difficulty: Difficult

PTS: 1

37. A postpartum woman being dismissed complains to the nurse that she has extreme fatigue, shoulder pain, and has noticed what looks like blood in her urine. Which laboratory finding would the nurse correlate with these symptoms?
A. Arterial blood pH: 7.35
B. Blood glucose: 100 mg/dL
C. Platelet count: 98,000/mm3
D. White blood cell count: 9,000/mm3
ANS: C
This woman has symptoms of possible HELLP syndrome, which is characterized by poor liver function and thrombocytopenia. The platelet count is very low, consistent with this condition. The other laboratory values are within normal limits.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

38. A nurse is preparing to dismiss a woman and her infant from the hospital. The woman is Rh(D)-negative and the infant is Rh(D)-positive. This was her first pregnancy. Which nursing action is most appropriate?
A. Administer Rho(D) immune globulin (RhoGAM) and document accurately.
B. Assess the father to see if he has ever received an injection of RhoGAM.
C. Educate the woman on the need for RhoGAM if she delivers an Rh(D)-negative baby.
D. Instruct the woman to get RhoGAM with her next pregnancy, not for this one.
ANS: A
Administering RhoGAM correctly and documenting it is a critical nursing action when indicated. An unsensitized Rh(D)-negative woman should be given RhoGAM within 72 hours of delivery of an Rh(D)-positive baby. RhoGAM is not administered to the father or to the baby. If an Rh(D)-negative woman gives birth to an Rh(D)-negative baby, she does not need RhoGAM. The woman should be tested for sensitivity during her next, and all subsequent, pregnancies.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

39. A woman with a history of heart failure is in labor and has the following vital signs: blood pressure: 100/58 mm Hg, pulse: 120 beats/minute, respiratory rate: 36 breaths/minute, oxygen saturation: 88%. Which action should the nurse perform first?
A. Administer oxygen at 10 L/min per rebreather mask.
B. Call the health-care provider to report the results.
C. Document the findings in the patients chart.
D. Increase the womans IV infusion to 150 mL/hour.
ANS: A
The patient is exhibiting signs of decreased cardiac output and her low SaO2 indicates that she needs oxygen, which should be supplied at 10 L/min per rebreather mask. Calling the provider and documentation are important actions but do not take priority over promptly treating the woman. She does not need increased IV fluids, and, in fact, increasing the IV fluid rate will likely worsen her condition.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

40. A patient on the high-risk OB unit is receiving magnesium sulfate. The nurse notes that her magnesium level is 14 mEq/L. Which of the following actions by the nurse is most appropriate?
A. Bring the crash cart to the patients room.
B. Document the findings in the womans chart.
C. Order another blood level in 6 hours.
D. Prepare to administer calcium gluconate.
ANS: D
This womans magnesium level has nearly reached the level associated with respiratory arrest. The nurse should prepare to administer the antidote, 10% calcium gluconate. The nurse should have someone else bring the crash cart into the room in case respiratory arrest does occur. Documentation is important, but this needs to be done after the woman is cared for. Additional magnesium levels will be drawn, but ordering them now instead of treating the patient is an inappropriate action.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

41. A pregnant woman who has diabetes mellitus is in the high-risk OB clinic for a checkup. The nurse notes that her hemoglobin A1C (HbAIC) is 5%. Which action by the nurse is most appropriate?
A. Arrange a referral to the diabetic nurse educator.
B. Assess for factors leading to noncompliance.
C. Document the findings in the patients chart.
D. Schedule another HbAIC in 4 weeks.
ANS: C
Control of maternal glucose levels (< 7.0% in overtly diabetic women) is an important factor in determining fetal outcome. The glycosylated hemoglobin A1c (HbA1c) level is commonly assessed to guide adjustments in the treatment plan throughout pregnancy. Because the maternal serum HbA1c reflects the degree of glycemic control during the preceding 5 to 6 weeks, the test is repeated every trimester. Good diabetic control is reflected by an HbA1c value of 2.5% to 5.9%; an HbA1c value greater than 8% is indicative of poor diabetic control. Because the patients value indicates good control, the most appropriate action is documentation. The patient may need to see the diabetic nurse educator, depending on other nursing assessments or patient desire.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

42. A pregnant patient is admitted with possible deep venous thrombosis (DVT). Orders are left to start warfarin (Coumadin) 5 mg p.o., once daily. Which of the following actions by the nurse is most appropriate?
A. Call the physician to clarify the order and document the conversation.
B. Instruct the patient not to get out of bed without assistance.
C. Start the warfarin as soon as it is available from the pharmacy.
D. Teach the patient about the risks and benefits of anticoagulation.
ANS: A
Coumadin is contraindicated in pregnant women because it crosses the placenta. If anticoagulation is needed, heparin is the drug of choice. The nurse should consult with the physician about the orders and carefully document the conversation and results. Teaching is an appropriate nursing activity but is not the priority. The patient on heparin should be counseled to call for assistance before getting up because of the risk for injury, but the priority is obtaining the correct drug. The nurse should not start the Coumadin.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

43. A pregnant woman is HIV-positive. She is asking about ways to decrease the risk of vertical transmission to her baby. Which option given by the nurse would confer the least risk to the baby?
A. Antiretroviral medications (zidovudine [ZDV])
B. Cesarean delivery
C. Cesarean delivery plus antiretroviral medications for the newborn
D. Vaginal delivery plus antiretroviral medications for the newborn
ANS: C
Women with HIV should be counseled that the risk of vertical transmission (mother to child) is 25% without antiretroviral medication. With ZDV, the rate is 5 to 8%. When both options are combined, the risk drops to around 2%, so this is the best option.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

44. A nurse is caring for a pregnant woman on the high-risk OB unit who is anticipating a long stay on bedrest. Which action by the nurse would be most helpful to help diminish the physical complications associated with imposed bedrest?
A. Arrange a social work consult for coping assessment.
B. Assess and document the womans skin each shift.
C. Consult physical therapy for in-bed exercises.
D. Help the woman select high-protein foods from the menu.
ANS: C
All activities are appropriate for a woman who is confined to bed prior to childbirth. However, to mitigate the possible physical complications from bedrest, encouraging activity and exercise to her limits is desirable. A physical therapist can design an exercise routine the patient can do in bed. A coping assessment would help with psychosocial complications. Assessing and documenting skin condition does not diminish complications. Nutrition is important and selecting appropriate foods is helpful, but the major complications from bedrest occur in the cardiovascular system.

Cognitive Level: Applying/Application
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

45. A nurse manager on the OB unit is auditing patient charts. One record documents the care of a patient having a seizure. The record describes the time and length of the seizure, medications given, maternal and fetal vital signs, and outcome of treatment. Which action by the manager is best?
A. Compare the chart with charts of similar patients.
B. Educate the staff on better documentation practices.
C. Have the nurse rewrite the documentation.
D. No action is needed; continue with chart audits.
ANS: B
The elements of complete documentation include what was charted plus associated symptoms, presence (or absence) of uterine contractions, and the presence of other obstetrical complications (e.g., rupture of membranes). The manager should educate all nurses in the unit about complete documentation needed for patients having a seizure. There is no need to compare this chart with others, and the nurse should not rewrite the documentation (although the nurse may need to use an addendum, depending on how old the record is).

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

MULTIPLE RESPONSE

1. The perinatal nurse is educating a group of women on common causes of miscarriage, or spontaneous abortion. Which of the following does the nurse describe? (Select all that apply.)
A. Cervical anatomic defects
B. Chromosomal abnormalities
C. Maternal infections
D. Recreational drug use
E. Working during pregnancy
ANS: A, B, C, D
Early spontaneous abortions have been linked to chromosomal abnormalities, infections, maternal anatomical defects, and immunological and endocrine factors. In some cases, no cause is found. Second-trimester spontaneous abortions can be caused by chronic infection, recreational drug use, maternal uterine or cervical anatomical defects, maternal systemic disease, exposure to fetotoxic agents, and trauma. In general, working during pregnancy is not a risk factor, although the nurse should assess the womans work setting for environmental/work-related risks, such as fetotoxic agents or ionizing radiation.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. A nurse is conducting an educational class for expectant couples. What information about preterm birth does the nurse include in the discussion? (Select all that apply.)
A. A diagnosis of preterm labor requires cervical changes.
B. African Americans have the lowest rate of preterm birth of all ethnic groups.
C. The vast majority of infants born at 29 weeks gestation survive.
D. Today, 1 in 25 babies are born prematurely in America.
E. Worldwide, preterm birth is the leading cause of neonatal morbidity and mortality.
ANS: A, C, E
Although many pregnant women experience preterm contractions, only those with cervical changes are diagnosed with preterm labor. More than 90% of infants born at 2829 weeks gestation survive today. Worldwide, premature birth is the leading cause of infant morbidity and mortality. According to the March of Dimes (2012), the rate of preterm birth is highest for African American infants (18.4 %). In the United States, more than 1 in 8 babies are born too soon.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

3. Which of the following does the nurse recognize as complications of premature birth? (Select all that apply.)
A. Osteoporosis
B. Cerebral palsy and mental retardation
C. Diabetes mellitus type 1
D. Intraventricular hemorrhage
E. Retinopathy of prematurity
ANS: B, D, E
Some short-term neonatal morbidities associated with preterm birth include respiratory distress syndrome, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and patent ductus arteriosus. Long-term morbidities include cerebral palsy, mental retardation, and retinopathy of prematurity. Osteoporosis and
diabetes are not known complications of premature birth.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

4. A nurse is teaching a woman the actions to take in the event the woman believes she is in preterm labor. Which of the following should the nurse include in the teaching plan? (Select all that apply.)
A. Come to the hospital immediately if you dont feel contractions.
B. Drink 2 to 3 glasses of a non-caffeinated beverage after emptying your bladder.
C. Feel for uterine contractions for the next 2 to 3 hours.
D. Lie down on your back with pillows under your knees.
E. Seek additional health care if you have 4 or more contractions in 1 hour.
ANS: B, E
The nurse should instruct the woman to empty her bladder, lie down on her side, drink 2 to 3 non-caffeinated beverages, feel for uterine contractions, and either go to the hospital or call the health-care provider if she feels 4 or more contractions in 1 hour. She should not lie down on her back or assess for contractions for over an hour.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

5. A nurse is caring for a woman on a continuous IV of magnesium sulfate. Which actions are appropriate for patient safety? (Select all that apply.)
A. Administer the bolus from the main bag, then change to the maintenance rate.
B. Double-check each new bag and dose/rate change with another nurse.
C. Ensure that a supply of romazicon (Flumazenil) is available in the patients room.
D. Perform handoff report at the bedside, verifying the dose and orders by both nurses.
E. Place color-coded tags on each IV line, bag, and pump to label them clearly.
ANS: B, D, E
Magnesium sulfate is a high-risk, high-alert drug and the nurse must be cautious about administering this drug safely. Some appropriate actions include double-checking any rate or dose changes with a second nurse, performing the handoff report at the bedside so that both nurses can verify the orders and compare them to the IV bag and pump rate, and color-coding IV lines, bags, and pumps for easy identification. The nurse should ensure that a supply of the antidote (calcium gluconate 10%) is available. However, romazicon is the antidote for benzodiazepine overdose. The nurse should use a small-volume IV piggyback for the bolus dose instead of using the main bag to give the bolus to the patient, and then change the infusion rate to the maintenance setting.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

6. A nurse is conducting a nonstress test on a pregnant woman. The nurse understands that which of the following conditions can lead to loss of fetal heart rate reactivity?
A. Central nervous system irritability
B. Certain congenital abnormalities
C. Fetal acidbase disturbance
D. Fetal hypoxia
E. Fetal sleep cycle
ANS: B, C, D, E
The most common cause of loss of fetal heart rate reactivity is a fetal sleep cycle. Other causes are related to central nervous system depression (not irritability) and can include fetal acidosis, hypoxia, and certain congenital abnormalities.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

7. A perinatal nurse is working with a woman who has had four perinatal losses in the first 20 weeks of pregnancy. The nurse should anticipate orders for which of the following diagnostic tests? (Select all that apply.)
A. Cervical cultures
B. Hysterosalpingogram
C. Maternal/paternal karyotype
D. Sickle cell screening
E. Thyroid-stimulating hormone (TSH) levels
ANS: A, B, C, E
Patients who experience habitual (three or more) spontaneous abortions may be offered these tests as part of the diagnostic workup: a karyotype obtained from the products of conception and from both parents and an examination of the maternal anatomy, beginning with a hysterosalpingogram. Additional testing may include hysteroscopy or laparoscopy; screening tests for maternal hypothyroidism, diabetes mellitus, antiphospholipid syndrome (APS), and systemic lupus erythematosus (SLE); testing of the serum progesterone level during the luteal phase of the menstrual cycle; cultures of the cervix, vagina, and endometrium; and endometrial biopsy during the luteal phase of the menstrual cycle. Sickle cell screening would not be part of this workup.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

8. A nurse is caring for a laboring woman from an unfamiliar culture who has limited English skills. Which nursing actions are important to provide nursing care to this patient? (Select all that apply.)
A. Allow artifacts that have religious or cultural significance to remain with the woman.
B. Assess the womans beliefs about childbirth, breastfeeding, and postpartum nutrition.
C. Communicate with the woman and family using a professional interpreter.
D. Identify community resources that are culturally appropriate and acceptable.
E. Restrict visitors to one person who can then communicate with the other family members.
ANS: A, B, C, D
Working with patients from unfamiliar cultures can be challenging, especially if the patient has limited English skills. Ways to improve nursing care delivered to these patients includes using a professional interpreter, assessing relevant cultural beliefs, allowing items that hold special religious or cultural significance to remain with the woman, and finding community resources that are culturally acceptable and appropriate. Restricting visitors may cause resentment and suspicion.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

9. A nurse is assessing all patients in the perinatal clinic for culturally related increased risk for gestational diabetes mellitus. Which patients would the nurse assess as being in the highest risk groups? (Select all that apply.)
A. African American
B. Caucasian
C. Chinese
D. Hispanic
E. Native American
ANS: A, C, D, E
Ethnic groups with a higher incidence of gestational diabetes mellitus include African Americans, Asian Americans, Hispanics, and Native Americans. Pacific Islanders also have increased risk. Caucasians do not have an increased risk.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

10. A nurse in the perinatal clinic explains to a student nurse that which of the following patients are at highest risk of developing gestational diabetes? (Select all that apply.)
A. A17-year-old in her second pregnancy
B. A 24-year-old pregnant woman with placenta previa
C. A 32-year-old woman with a BMI of 40
D. A woman whose first baby weighed 10.5 lb (4.7 kg)
E. A woman whose mother and sister had gestational diabetes
ANS: C, D, E
The risk factors for developing gestational diabetes include age older than 25; obesity; insulin resistance; polycystic ovary syndrome; history of pregnancy-related diabetes mellitus; history of a large-for-gestational age infant; hydramnios, stillbirth, miscarriage, or an infant with congenital anomalies during a previous pregnancy; family history of type 2 diabetes (first-degree relative); and ethnicity. Being young does not confer additional risk, nor does placenta previa. The 32-year-old is obese, the 10.5-lb baby is large for gestational age, and the mother and sister are first-degree relatives.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

11. The perinatal nurse describes risk factors for placenta previa to the student nurse. Which of the following risk factors does the nurse include? (Select all that apply.)
A. Cocaine use
B. Previous cesarean birth
C. Previous use of medroxyprogesterone (Depo-Provera)
D. Tobacco use
E. Young maternal age
ANS: A, B, D
Placenta previa may be associated with conditions that cause scarring of the uterus such as prior cesarean birth, multiparity, or increased maternal age. Placenta previa may also occur with a large placental mass, as seen in multiple gestations and erythroblastosis. Other risk factors for placenta previa include smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years (Clark, 2004).

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

12. A pregnant woman in her second trimester arrives at the labor unit triage station with complaints of lower abdominal cramping and urinary frequency. Appropriate nursing actions include which of the following? (Select all that apply.)
A. Assess the fetal heart rate.
B. Assess the patients pulse rate.
C. Insert an indwelling Foley catheter.
D. Obtain a urine sample for culture and sensitivity.
E. Palpate the patients abdomen for contractions.
ANS: A, B, D, E
Women who experience preterm labor may complain of backache, pelvic aching, menstrual-type cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity should be obtained on all patients with symptoms of preterm labor, and the nurse must remember that symptoms of urinary tract infection often mimic normal pregnancy complaints (e.g., urgency, frequency). The patients abdomen should be palpated to assess for contractions, and the fetal heart rate should be monitored. It is not necessary to insert a Foley catheter at this time.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

13. The perinatal nurse knows that tocolytic agents are most often used to do which of the following? (Select all that apply.)
A. Allow for transport of the woman to a tertiary care facility
B. Facilitate administration of antenatal corticosteroids
C. Prevent development of fetal respiratory distress syndrome
D. Prevent maternal infection
E. Prolong pregnancy as long as possible
ANS: A, B
Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of maternal antenatal corticosteroids to accelerate fetal lung maturity. In addition, delaying the preterm birth provides time for maternal transport to a facility that is equipped with a neonatal intensive care unit. Tocolytics themselves do not prevent the development of respiratory complications such as respiratory distress syndrome. Tocoytic agents do not prevent infection and are recommended for use only up to 48 hours.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

14. A nurse is caring for a pregnant 16-year-old who is homeless and occasionally spends time in a homeless shelter. She has been seen in the clinic before for sexually transmitted infections (STIs). She weighs 92 lb (41.8 kg) and occasionally uses crack cocaine. Which risk factors does this patient have for a negative pregnancy outcome? (Select all that apply.)
A. Age of 16 years
B. Being homeless
C. Crack cocaine use
D. History of STIs
E. Low weight
ANS: B, C, D, E
According to Barry (2011) and Porter and Holness (2011), prenatal medical and behavioral risks for the adolescent population include preterm labor and birthespecially when combined with low socioeconomic status, being a single parent, being a smoker, using illicit drugs, prepregnant weight less than 100 lb (45.5 kg), poor weight gain during pregnancy, and inadequate prenatal care. Other factors include anemia; preeclampsia-eclampsia; repeated exposure to sexually transmitted infections; chronic or asymptomatic urinary tract infections; acute pyelonephritis; intrauterine growth restriction/low-birth-weight infants (< 2,500 g); and social issues such as poverty, unmarried status, low educational levels, smoking, and drug use. After age 15 years, the adolescent does not experience any more problems than does the general population.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

OTHER

1. Match the terms on the left with the statements on the right. Answers may be used once, more than once, or not at all.

a. Placenta previa _____ Can be described as complete, partial, or marginal

b. Abruptio placentae _____ Condition in which the umbilical cord is implanted in the membranes rather than in the placenta
c. Vasa previa _____ May be associated with previous cesarean birth

_____ One risk factor is closely spaced pregnancies

_____ Premature separation of the normally implanted placenta from the lining of the uterus
_____ Can resolve as the uterus enlarges in the third trimester

_____ Maternal abdominal trauma is one risk factor

_____ Classic sign is vaginal bleeding and severe abdominal pain in the third trimester
ANS:
a, c, a, a, b, a, b, b

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

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