Chapter 12: Pregnancy at Risk: Gestational Conditions Nursing School Test Banks

Chapter 12: Pregnancy at Risk: Gestational Conditions

MULTIPLE CHOICE

1. Women with hyperemesis gravidarum:

a.

Are a majority, because 80% 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.

ANS: B

Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 80% of pregnant women experience nausea and vomiting, fewer than 1% (0.5%) proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is 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: 316

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. 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.

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: 333

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?

a.

Bleeding time of 10 minutes

c.

Thrombocytopenia

b.

Presence of fibrin split products

d.

Hyperfibrinogenemia

ANS: B

Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 330

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:

a.

Disseminated intravascular coagulation (DIC)

b.

Amniotic fluid embolism (AFE)

c.

Hemorrhage

d.

HELLP syndrome

ANS: A

The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the womans arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the postpartum client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 331

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

5. In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?

a.

Administration of blood

b.

Preparation of the client for invasive hemodynamic monitoring

c.

Restriction of intravascular fluids

d.

Administration of steroids

ANS: A

Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a client with DIC because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 332

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

6. 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

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 in diastolic pressure of 15 mm Hg. 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: 303

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

7. The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the womans latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of:

a.

Eclampsia.

b.

Disseminated intravascular coagulation (DIC).

c.

HELLP syndrome.

d.

Idiopathic thrombocytopenia.

ANS: C

HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 306

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

8. A woman with preeclampsia has a seizure. The nurses 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.

ANS: D

If a client becomes eclamptic, the nurse should stay 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 clients head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the clients mouth. Oxygen would be administered after the convulsion has ended.

PTS: 1 DIF: Cognitive Level: Application REF: 309

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

9. 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 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, Im 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.

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 greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.

PTS: 1 DIF: Cognitive Level: Application REF: 311

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

10. 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.

ANS: A

Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 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: 313

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

11. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:

a.

Eclamptic seizure.

c.

Placenta previa.

b.

Rupture of the uterus.

d.

Placental abruption.

ANS: D

Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 326

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

12. The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits:

a.

A sleepy, sedated affect.

c.

Deep tendon reflexes of 2.

b.

A respiratory rate of 10 breaths/min.

d.

Absent ankle clonus.

ANS: B

A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2 and absent ankle clonus are normal findings.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 312

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

13. Your patient has been receiving magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client?

a.

Absence of uterine bleeding in the postpartum period

b.

A fundus firm below the level of the umbilicus

c.

Scant lochia flow

d.

A boggy uterus with heavy lochia flow

ANS: D

Because of the tocolytic effects of magnesium sulfate, this patient most likely would have a boggy uterus with increased amounts of bleeding and a heavy lochia flow in the postpartum period.

PTS: 1 DIF: Cognitive Level: Analysis REF: 312

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. Your patient is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, Why is it taking so long? The most appropriate response by the nurse would be:

a.

The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.

b.

I dont know why it is taking so long.

c.

The length of labor varies for different women.

d.

Your baby is just being stubborn.

ANS: A

Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate. I dont know why it is taking so long is not an appropriate statement for the nurse to make. Although the length of labor does vary in different women, the most likely reason this womans labor is protracted is the tocolytic effect of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.

PTS: 1 DIF: Cognitive Level: Application REF: 311

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

15. 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 MgSO4

d.

Risk for increased cardiac output related to use of antihypertensive drugs

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: 311

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

16. The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:

a.

Hypertension.

c.

Hemorrhagic complications.

b.

Hyperemesis gravidarum.

d.

Infections.

ANS: A

Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 303

OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

17. 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.

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: 306

OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

18. Nurses should be aware that chronic hypertension:

a.

Is defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy.

b.

Is considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg.

c.

Is general hypertension plus proteinuria.

d.

Can occur independently of or simultaneously with gestational hypertension.

ANS: D

Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks postpartum. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 308

OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

19. In planning care for women with preeclampsia, nurses should be aware that:

a.

Induction of labor is likely, as near term as possible.

b.

If at home, the woman should be confined to her bed, even with mild preeclampsia.

c.

A special diet low in protein and salt should be initiated.

d.

Vaginal birth is still an option, even in severe cases.

ANS: A

Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 308

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

20. Magnesium sulfate is given to women with preeclampsia and eclampsia to:

a.

Improve patellar reflexes and increase respiratory efficiency.

b.

Shorten the duration of labor.

c.

Prevent and treat convulsions.

d.

Prevent a boggy uterus and lessen lochial flow.

ANS: C

Magnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 315

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

21. Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors?

a.

A 30-year-old obese Caucasian with her third pregnancy

b.

A 41-year-old Caucasian primigravida

c.

An African-American client who is 19 years old and pregnant with twins

d.

A 25-year-old Asian-American whose pregnancy is the result of donor insemination

ANS: C

Three risk factors are present for this woman. She is of African-American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy. In planning care for this client the nurse must monitor blood pressure frequently and teach the woman regarding early warning signs. The 30-year-old client only has one known risk factor, obesity. Age distribution appears to be U-shaped, with women less than 20 years and more than 40 years being at greatest risk. Preeclampsia continues to be seen more frequently in primigravidas; this client is a multigravida woman. Two risk factors are present for the 41-year-old client. Her age and status as a primigravida put her at increased risk for preeclampsia. Caucasian women are at a lower risk than African-American women. The Asian-American client exhibits only one risk factor. Pregnancies that result from donor insemination, oocyte donation, and embryo donation are at an increased risk of developing preeclampsia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 304

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

22. A woman presents to the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?

a.

Incomplete

c.

Threatened

b.

Inevitable

d.

Septic

ANS: C

A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would present with heavy bleeding, mild to severe cramping, and cervical dilation. An inevitable abortion manifests with the same symptoms as an incomplete abortion: heavy bleeding, mild to severe cramping, and cervical dilation. A woman with a septic abortion presents with malodorous bleeding and typically a dilated cervix.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 319

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

23. The perinatal nurse is giving discharge instructions to a woman after suction 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.

ANS: B

This is an accurate statement. b-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 could 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: 325

OBJ: Nursing Process: Planning, Implementation

MSC: Client Needs: Physiologic Integrity

24. The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:

a.

Bleeding.

c.

Uterine activity.

b.

Intense abdominal pain.

d.

Cramping.

ANS: B

Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 330

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

25. 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

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: 324

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

26. 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

b.

Ultrasound for placental location

c.

Contraction stress test (CST)

d.

Internal fetal monitoring

ANS: B

The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding.

PTS: 1 DIF: Cognitive Level: Application REF: 328

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

27. A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of:

a.

Placenta previa.

b.

Vasa previa.

c.

Severe abruptio placentae.

d.

Disseminated intravascular coagulation (DIC).

ANS: B

Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and would be considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors and causes widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome. This woman did not have any prior risk factors.

PTS: 1 DIF: Cognitive Level: Analysis REF: 330

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

28. A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the womans umbilicus and recognizes this assessment finding as:

a.

Normal integumentary changes associated with pregnancy.

b.

Turners sign associated with appendicitis.

c.

Cullens sign associated with a ruptured ectopic pregnancy.

d.

Chadwicks sign associated with early pregnancy.

ANS: C

Cullens sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turners sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwicks sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy.

PTS: 1 DIF: Cognitive Level: Analysis REF: 323

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

29. As related to the care of the patient with miscarriage, nurses should be aware that:

a.

It is a natural pregnancy loss before labor begins.

b.

It occurs in fewer than 5% of all clinically recognized pregnancies.

c.

It often can be attributed to careless maternal behavior such as poor nutrition or excessive exercise.

d.

If it occurs before the twelfth week of pregnancy, it may manifest only as moderate discomfort and blood loss.

ANS: D

Before the sixth week the only evidence may be a heavy menstrual flow. After the twelfth week more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but by definition it occurs before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriage can be caused by a number of disorders or illnesses outside of the mothers control or knowledge.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 319

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

30. Which condition would not be classified as a bleeding disorder in late pregnancy?

a.

Placenta previa.

c.

Spontaneous abortion.

b.

Abruptio placentae.

d.

Cord insertion.

ANS: C

Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Cord insertion is a cause of bleeding disorders in later pregnancy.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 318

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

31. In providing nutritional counseling for the pregnant woman experiencing cholecystitis, the nurse would:

a.

Assess the womans dietary history for adequate calories and proteins.

b.

Instruct the woman that the bulk of calories should come from proteins.

c.

Instruct the woman to eat a low-fat diet and avoid fried foods.

d.

Instruct the woman to eat a low-cholesterol, low-salt diet.

ANS: C

Instructing the woman to eat a low-fat diet and avoid fried foods is appropriate nutritional counseling for this client. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 333

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

32. Which maternal condition always necessitates delivery by cesarean section?

a.

Partial abruptio placentae

c.

Ectopic pregnancy

b.

Total placenta previa

d.

Eclampsia

ANS: B

In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred. If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted in cases of partial abruptio placentae. If the fetus has died, a vaginal delivery is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 328

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

33. Spontaneous termination of a pregnancy is considered to be an abortion if:

a.

The pregnancy is less than 20 weeks.

b.

The fetus weighs less than 1000 g.

c.

The products of conception are passed intact.

d.

No evidence exists of intrauterine infection.

ANS: A

An abortion is the termination of pregnancy before the age of viability (20 weeks).

The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 318

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

34. An abortion in which the fetus dies but is retained within the uterus is called a(n):

a.

Inevitable abortion

c.

Incomplete abortion

b.

Missed abortion

d.

Threatened abortion

ANS: B

Missed abortion refers to retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 331

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

35. A placenta previa in which the placental edge just reaches the internal os is more commonly known as:

a.

Total

c.

Complete

b.

Partial

d.

Marginal

ANS: D

A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. When the patient experiences a partial placenta previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete placenta previa is termed total. The placenta completely covers the internal cervical os.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 326

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

36. What condition indicates concealed hemorrhage when the patient experiences an abruptio placentae?

a.

Decrease in abdominal pain

c.

Hard, boardlike abdomen

b.

Bradycardia

d.

Decrease in fundal height

ANS: C

Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. Abdominal pain may increase. The patient will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height will increase.

PTS: 1 DIF: Cognitive Level: Analysis REF: 330

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

37. The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to:

a.

Assess fetal heart rate (FHR) and maternal vital signs

b.

Perform a venipuncture for hemoglobin and hematocrit levels

c.

Place clean disposable pads to collect any drainage

d.

Monitor uterine contractions

ANS: A

Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later.

It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 326

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

38. A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of:

a.

Anxiety due to hospitalization.

b.

Worsening disease and impending convulsion.

c.

Effects of magnesium sulfate.

d.

Gastrointestinal upset.

ANS: B

Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication.

PTS: 1 DIF: Cognitive Level: Analysis REF: 308

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

39. Which order should the nurse expect for a patient admitted with a threatened abortion?

a.

Bed rest

b.

Ritodrine IV

c.

NPO

d.

Narcotic analgesia every 3 hours, prn

ANS: A

Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. There is no reason for having the woman placed NPO. At times dehydration may produce contractions, so hydration is important. Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 319

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

40. What finding on a prenatal visit at 10 weeks could suggest a hydatidiform mole?

a.

Complaint of frequent mild nausea

b.

Blood pressure of 120/80 mm Hg

c.

Fundal height measurement of 18 cm

d.

History of bright red spotting for 1 day, weeks ago

ANS: C

The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the patients history, bleeding is normally described as brownish.

PTS: 1 DIF: Cognitive Level: Analysis REF: 325

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

41. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that:

a.

Bed rest and analgesics are the recommended treatment.

b.

She will be unable to conceive in the future.

c.

A D&C will be performed to remove the products of conception.

d.

Hemorrhage is the major concern.

ANS: D

Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture in order to prevent hemorrhaging. If the tube must be removed, the womans fertility will decrease; however, she will not be infertile.

D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 323

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

42. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion?

a.

Chromosomal abnormalities

c.

Endocrine imbalance

b.

Infections

d.

Immunologic factors

ANS: A

At least 50% of pregnancy losses result from chromosomal abnormalities that are incompatible with life. Maternal infection may be a cause of early miscarriage. Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss. Women who have repeated early pregnancy losses appear to have immunologic factors that play a role in spontaneous abortion incidents.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 318

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

43. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve:

a.

Corticosteroids to reduce inflammation.

b.

IV therapy to correct fluid and electrolyte imbalances.

c.

An antiemetic, such as pyridoxine, to control nausea and vomiting.

d.

Enteral nutrition to correct nutritional deficits.

ANS: B

Initially, the woman who is unable to keep down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 317

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

44. A client who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include (Select all that apply):

a.

Iron supplementation.

b.

Resumption of intercourse at 6 weeks following the procedure.

c.

Referral to a support group if necessary.

d.

Expectation of heavy bleeding for at least 2 weeks.

e.

Emphasizing the need for rest.

ANS: A, C, E

The woman should be advised to consume a diet high in iron and protein. For many women iron supplementation also is necessary. Acknowledge that the client has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her provider.

PTS: 1 DIF: Cognitive Level: Application REF: 320

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

45. The reported incidence of ectopic pregnancy in the United States has risen steadily over the past 2 decades. Causes include the increase in STDs accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for symptoms such as (Select all that apply):

a.

Pelvic pain

b.

Abdominal pain

c.

Unanticipated heavy bleeding

d.

Vaginal spotting or light bleeding

e.

Missed period

ANS: A, B, D, E

A missed period or spotting can easily be mistaken by the patient as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the patient often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.

PTS: 1 DIF: Cognitive Level: Application REF: 323

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

MATCHING

Because most pregnant women continue their usual activities, trauma remains a common complication during pregnancy. Approximately 30,000 women in the United States experience treatable injuries related to trauma each year. As a result of the physiologic alterations that accompany pregnancy, special considerations for mother and fetus are necessary when trauma occurs. Match the maternal system adaptation in pregnancy with the clinical response to trauma.

a.

Increased oxygen consumption

d.

Displacement of abdominal viscera

b.

Increased heart rate

e.

Increase in clotting factors

c.

Decreased gastric motility

46. Decreased placental perfusion in supine position

47. Increased risk of thrombus formation

48. Altered pain referral

49. Increased risk of acidosis

50. Increased risk of aspiration

46. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 335 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant trauma patient. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal wellbeing. Trauma may affect a number of systems within the body, and it is important for the nurse caring for this patient to be aware of normal system alterations in the pregnant woman. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity, and the degree of disruption of uterine and fetal physiologic features.

47. ANS: E PTS: 1 DIF: Cognitive Level: Application

REF: 335 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant trauma patient. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal wellbeing. Trauma may affect a number of systems within the body, and it is important for the nurse caring for this patient to be aware of normal system alterations in the pregnant woman. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity, and the degree of disruption of uterine and fetal physiologic features.

48. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 335 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant trauma patient. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal wellbeing. Trauma may affect a number of systems within the body, and it is important for the nurse caring for this patient to be aware of normal system alterations in the pregnant woman. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity, and the degree of disruption of uterine and fetal physiologic features.

49. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 335 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant trauma patient. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal wellbeing. Trauma may affect a number of systems within the body, and it is important for the nurse caring for this patient to be aware of normal system alterations in the pregnant woman. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity, and the degree of disruption of uterine and fetal physiologic features.

50. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 335 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant trauma patient. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal wellbeing. Trauma may affect a number of systems within the body, and it is important for the nurse caring for this patient to be aware of normal system alterations in the pregnant woman. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity, and the degree of disruption of uterine and fetal physiologic features.

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