Chapter 20: Assessment of the Pregnant Patient Nursing School Test Banks

Chapter 20: Assessment of the Pregnant Patient
Test Bank

MULTIPLE CHOICE

1. A patient who is 30 weeks pregnant tells the nurse, I have had low blood pressure all my life, and now it is 136/74. Whats wrong with me? What is the most appropriate response by this nurse?
a. A womans blood pressure usually drops several points during pregnancy, but yours hasnt.
b. The blood pressure increases because your blood volume increases to supply you and the baby with enough blood.
c. Yes, this is a significant change from your baseline, and I advise you to see your obstetrician at your earliest convenience.
d. If you spend more time lying down, I think your blood pressure should return to normal in a few days.
ANS: B

Feedback
A The blood pressure may decrease slightly in the second trimester and then return to the usual level during the third trimester. With an increase in blood volume, the patient may experience an increase in blood pressure above baseline.
B Blood volume increases by 1500 mL to meet the needs of an enlarged uterus and fetal tissue, causing increased cardiac workload (increased heart rate and blood pressure).
C This referral is unnecessary.
D With an increase in blood volume, the patient may experience an increase in blood pressure above baseline.
DIF: Cognitive Level: Apply REF: 496
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

2. A nurse instructs the patient about which expected skin changes during pregnancy?
a. Nipples becoming thicker
b. Hands and feet becoming pale and cool
c. Blotchy, brown pigmentation of the abdomen
d. Stretch marks on the expanding abdomen
ANS: D

Feedback
A Nipples and areolae become more prominent and deeply pigmented.
B Blood volume increases and edema often develops in the feet.
C The blotchy, brown pigmentation occurs on the face and is called chloasma, or the mask of pregnancy.
D The increasing size of the abdomen contributes to striae gravidarum (stretch marks) over the abdomen.
DIF: Cognitive Level: Understand REF: 496| 505
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

3. How does a nurse determine the Goodell sign?
a. Assesses the softening of the lower uterine segment
b. Palpates for softening of the cervix
c. Assesses the breasts for fullness and tenderness
d. Inspects the cervix for a bluish coloration
ANS: B

Feedback
A Assesses the softening of the lower uterine segment is a description of Hegar sign.
B Palpates for softening of the cervix is a description of Goodell sign.
C Assesses the breasts for fullness and tenderness is a presumptive sign of pregnancy rather than a probable sign.
D Inspects the cervix for a bluish coloration is a description of Chadwick sign.
DIF: Cognitive Level: Understand REF: 496, Table 20-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

4. The nurse recognizes which clinical manifestation as a positive sign of pregnancy?
a. Cessation of menstruation
b. Visualization of the fetus by ultrasound
c. Nausea and increased abdominal girth
d. Positive pregnancy test (hCG)
ANS: B

Feedback
A Cessation of menstruation is a presumptive sign of pregnancy.
B This is a positive sign of pregnancy.
C Nausea and increased abdominal girth are presumptive signs of pregnancy.
D Positive pregnancy test (hCG) is a probable sign of pregnancy.
DIF: Cognitive Level: Understand REF: 496, Table 20-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

5. Using Ngeles rule, what is the estimated delivery date of a patient whose last menstrual period started on December 1?
a. August 1
b. August 10
c. September 4
d. September 8
ANS: D

Feedback
A Subtract 3 months rather than 4, and add 7 days.
B Subtract 3 months rather than 4, and add 7 days rather than 9.
C After subtracting 3 months, add 7 days instead of 3.
D September 8 is determined by using the first day of the last menstrual period, subtracting 3 months, and adding 7 days.
DIF: Cognitive Level: Apply REF: 497
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

6. What is the meaning of G5, T1, P0, A3, L1 found in a patients history?
a. One birth at term
b. Three living children
c. Five grown children
d. One delivery not at term
ANS: A

Feedback
A These data report that this patient has had five pregnancies, one term birth, no preterm births, three abortions, and one living child.
B This patient has had three abortions.
C This patient has had five pregnancies.
D This patient has had no preterm births.
DIF: Cognitive Level: Apply REF: 497
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

7. A pregnant woman who drinks alcoholic beverages while pregnant increases the risk for which disorder?
a. Low infant birth weight
b. Birth defects
c. Abruptio placentae
d. Gestational diabetes mellitus
ANS: B

Feedback
A Low infant birth weight is not directly caused by alcohol intake.
B Alcohol is a teratogen; no safe level of alcohol ingestion has been identified for pregnant women.
C Maternal hypertension is the risk factor for abruptio placentae.
D Gestational diabetes mellitus is not caused by alcohol intake.
DIF: Cognitive Level: Understand REF: 498
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential

8. A nurse refers which pregnant patient for additional assessment?
a. A woman at 36 weeks of gestation who has 30% effacement of the cervix
b. A woman at 19 weeks of gestation who has noticed fetal movement every day this week
c. A woman at 20 weeks of gestation who has gained 4 lb in the last 2 weeks
d. A woman at 28 weeks of gestation who has a systolic blood pressure of 40 mg Hg over baseline
ANS: D

Feedback
A This is an expected finding at this point in the third trimester.
B This is an expected finding.
C This is an expected weight gain.
D This finding may indicate pregnancy-induced hypertension, characterized by systolic blood pressure of at least 30 mm Hg above baseline.
DIF: Cognitive Level: Analyze REF: 500
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

9. A patients prepregnant weight was 131 lb, within the desirable range for her height. What is the expected weight for this pregnant patient?
a. 131 lb at 1 week postpartum
b. 140 lb at the end of the first trimester
c. 145 lb at the end of the second trimester
d. 176 lb at the beginning of the third trimester
ANS: C

Feedback
A There are no specific weight guidelines for after birth, but it is unlikely that she would be at her prepregnant weight 1 week after delivery.
B The expected range for the first trimester is weight gain of 3 to 5 lb; the patient gained 9 lb.
C This 14-lb weight gain is within expected ranges (12 to 15 lb [5.5 to 6.8 kg]) for the second trimester.
D This 45-lb weight gain is 10 lb more than desired; the expected range for the third trimester is 12 to 15 lb greater than the second trimester, which would be 163 to 166 lb.
DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

10. A pregnant patient presents to the clinic with a 3 lb/wk weight gain for 2 successive weeks. The nurse is most concerned that this patient is demonstrating signs of which condition?
a. Gestational diabetes mellitus
b. Preeclampsia
c. Placenta enlargement
d. Multiple gestations
ANS: B

Feedback
A A rapid increase in weight could indicate gestational diabetes, but a gain of this much in 2 successive weeks warrants considering preeclampsia.
B If a woman gains more than 2 lb (0.9 kg) in any 1 week, preeclampsia should be suspected.
C Rapid weight gain is not associated with placental enlargement.
D A rapid increase in weight could indicate multiple gestation, but a gain of this much in 2 successive weeks warrants considering preeclampsia.
DIF: Cognitive Level: Analyze REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

11. A pregnant womans weight before becoming pregnant was 137 lb. What weight is expected for this woman during her second trimester?
a. 149 lb
b. 151 lb
c. 155 lb
d. 164 lb
ANS: C

Feedback
A This weight is obtained when you forget to include the 3 to 5 lb for the first trimester.
B The prepregnant weight was 137 lb. Add 3 to 5 lb for the first trimester, making the ranges from 140 to 142 lb. The second trimester is 12 to 15 lb in addition to the first trimester weight. This 140 to 142 lb + 12 to 15 lb = a range from 152 to 157 lb.
C The prepregnant weight was 137 lb. Add 3 to 5 lb for the first trimester, making the ranges from 140 to 142 lb. The second trimester is 12 to 15 lb in addition to the first trimester weight. This 140 to 142 lb + 12 to 15 lb = a range from 152 to 157 lb.
D This is the weight for the third trimester when an additional 12 to 15 lb can be added.
DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

12. A nurse documents as abnormal which finding of a pregnant patient?
a. Facial swelling in a woman who is 20 weeks pregnant
b. 1+ pitting ankle edema in a woman who is 26 weeks pregnant
c. Pinkish-red blotches of the hands in a woman at 32 weeks gestation
d. Blotchy, brownish pigmentation of the face in a woman at 36 weeks gestation
ANS: A

Feedback
A Excessive edema (particularly if noted in the hands and face in addition to the lower extremities) is considered pathologic and may be an indication of pregnancy induced hypertension.
B Some edema is expected during pregnancy and 1+ is a modest amount of edema.
C Pinkish-red blotches or diffuse mottling of the hands due to an increase in estrogen is termed palmar erythema and is considered an expected finding.
D Blotchy, brownish pigmentation of the facechloasma, or the mask of pregnancyis an expected finding.
DIF: Cognitive Level: Apply REF: 502
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

13. In prioritizing patient care, the nurse would give immediate attention to the pregnant patient with which clinical manifestation?
a. Darkened eyelids
b. Seeing spots
c. Excessive eye dryness
d. Pale conjunctiva
ANS: B

Feedback
A Darkened eyelids may occur normally and is not a reason for concern.
B Chromatopsia may be noted, characterized by unusual color perception, seeing spots, or blindness in the lateral visual field, and requires immediate follow-up.
C Excessive eye dryness occurs normally in pregnancy and can be treated with artificial tears.
D Pale conjunctiva may indicate anemia, which needs to be treated, but it is not an urgent problem.
DIF: Cognitive Level: Analyze REF: 502
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing Priorities

14. The nurse documents which clinical finding as an expected change associated with advancing pregnancy?
a. Slight persistent ankle edema
b. Hypoplasia of the thyroid gland
c. Increased diaphragmatic excursion
d. Heart murmur after 20 weeks of gestation
ANS: D

Feedback
A Ankle edema may occur, but normally is not persistent.
B This is not an expected finding in pregnancy.
C The diaphragm is pushed up by the growing fetus, which decreases the diaphragmatic excursion, rather than increasing it.
D Murmurs, splitting of S1 and S2, and the presence of S3 may be heard after the twentieth week of gestation.
DIF: Cognitive Level: Understand REF: 503
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

15. A patient at 20 weeks of gestation is concerned about a discharge from her nipples. What is the nurses appropriate response to this patient?
a. That is expected. It is milk production that begins at the onset of pregnancy.
b. A nipple discharge is unusual. I advise you to consult your obstetrician.
c. I suggest you decrease your fluid intake for several days to see if this makes a difference.
d. After the first trimester a thin, yellow fluid called colostrum may be secreted from the nipples.
ANS: D

Feedback
A Colostrum cannot be expressed until after the first trimester.
B This finding is not unusual.
C This action is not necessary because this is an expected finding.
D This is a correct statement by the nurse.
DIF: Cognitive Level: Understand REF: 504
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

16. A woman who is 16 weeks pregnant with her first child is concerned because she has not felt the fetus move. What is the most appropriate explanation for a nurse to give this patient?
a. Movement of a fetus in the first pregnancy often does not occur until the twenty-fourth week of pregnancy.
b. A referral to an obstetrician should be made for further evaluation of this finding.
c. Movement of the fetus is not expected until the nineteenth week of pregnancy.
d. Movement of the fetus is related to fundal height; the greater the fundal height, the sooner the fetal movement.
ANS: C

Feedback
A Fetal movement is felt by the nineteenth week and movement observed by approximately the twenty-eighth week.
B A referral is not warranted in this case.
C This patient will likely not feel fetal movement for another 3 weeks.
D Fetal movement is related to gestational age rather than fundal height.
DIF: Cognitive Level: Understand REF: 506
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

17. In measuring fundal height, the nurse documents which finding as abnormal?
a. 29 cm at week 30
b. 28 cm at week 26
c. 34 cm at week 38
d. 26 cm at week 24
ANS: C

Feedback
A From the twentieth to thirty-sixth week of gestation, the expected pattern of uterine growth is an increase in fundal height of about 1 cm per week.
B Measurement of fundal height is an estimate and may vary among examiners by 1 to 2 cm.
C This is a 4 cm difference; any discrepancy greater than 2 cm between fundal height and the estimate of gestational age (based on the last menstrual period) should be evaluated further.
D Measurement of fundal height is an estimate and may vary among examiners by 1 to 2 cm.
DIF: Cognitive Level: Apply REF: 506
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

18. A nurse assesses fetal heart rates when patients are examined in the maternity clinic. The nurse determines which fetus needs further assessment?
a. The fetus with a heart rate of 150 beats/min
b. The fetus with a heart rate of 140 beats/min
c. The fetus with a heart rate of 130 beats/min
d. The fetus with a heart rate of 110 beats/min
ANS: D

Feedback
A This heart rate is within the expected range of 120 to 160 beats/min.
B This heart rate is within the expected range of 120 to 160 beats/min.
C This heart rate is within the expected range of 120 to 160 beats/min.
D This fetal heart rate is too slow and needs further assessment. The expected range is from 120 to 160 beats/min.
DIF: Cognitive Level: Apply REF: 507
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing Priorities

19. To perform Leopold maneuvers, the nurse uses which assessment technique?
a. Percussing over the symphysis pubis
b. Auscultating all four abdominal quadrants
c. Palpating the fundus
d. Measuring from symphysis pubis to the umbilicus
ANS: C

Feedback
A This technique may be used to determine a full bladder.
B This technique determines presence of peristalsis.
C This is the procedure for Leopold maneuvers to determine presentation.
D This technique is used to determine the size of the fetus.
DIF: Cognitive Level: Understand REF: 508-509
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

20. The nurse correlates which clinical manifestation with the diagnosis of polyhydramnios?
a. Difficulty palpating fetal parts
b. Increased fetal movement
c. Weight gain of less than estimated by gestational age
d. Increase of 2 cm in fundal height in 1 week
ANS: A

Feedback
A Inability to palpate the fetal position could be associated with polyhydramnios, an excessive quantity of amniotic fluid.
B This is not a manifestation of excessive amniotic fluid.
C This is not a manifestation of excessive amniotic fluid.
D This is not a manifestation of excessive amniotic fluid.
DIF: Cognitive Level: Understand REF: 513
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

21. In reviewing the results of physical examination of a 25-year-old pregnant patient, a nurse recognizes which finding as expected?
a. Small, round, oval cervix
b. Pale, symmetrical cervix
c. Smooth, bluish-colored cervix
d. Slit-shaped, pink cervix
ANS: C

Feedback
A This describes a nulliparous cervix, but the patient referred to is pregnant, which would cause a bluish-colored cervix.
B The patient referred to is pregnant, which would cause a bluish-colored cervix.
C By the second month of pregnancy, the cervix, vagina, and vulva take on a bluish color (Chadwick sign) due to increased vascularity.
D The patient referred to is pregnant, which would cause a bluish-colored cervix.
DIF: Cognitive Level: Apply REF: 508
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

22. How does a nurse describe abruptio placentae when teaching a class to pregnant women?
a. A premature separation of the implanted placenta before birth of the fetus
b. An accumulation of amniotic fluid associated with decreased fetal movement
c. An attachment of the placenta in the lower uterine segment near the cervical os
d. Related to premature rupture of membranes with purulent vaginal discharge
ANS: A

Feedback
A A premature separation of the implanted placenta before birth of the fetus is a description of abruptio placentae.
B This is an incorrect description.
C This is a description of placenta previa.
D Abruptio placentae is premature separation of the implanted placenta rather than a premature rupture of membranes; there is no purulent vaginal discharge.
DIF: Cognitive Level: Understand REF: 512
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

23. Which complication of pregnancy does a nurse suspect when the patient reports painless vaginal bleeding at 32 weeks of gestation?
a. Placenta previa
b. Eclampsia
c. Abruptio placentae
d. Premature rupture of membranes
ANS: A

Feedback
A Placenta previa has painless vaginal bleeding as a manifestation.
B Eclampsia does not have painless vaginal bleeding as a manifestation.
C Abruptio placentae does not have painless vaginal bleeding as a manifestation.
D Premature rupture of membranes does not have painless vaginal bleeding as a manifestation.
DIF: Cognitive Level: Understand REF: 512-513
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

24. In assessing a patient for modifiable risk factors, the nurse correlates which finding with a high-risk pregnancy?
a. 15-year-old mother
b. Low socioeconomic status
c. Previous birth of infant with isoimmunization
d. Weight less than 100 lb
ANS: D

Feedback
A Age cannot be modified.
B Low socioeconomic status cannot be modified easily.
C Previous birth of infant with isoimmunization cannot be modified.
D This risk factor can be modified by diet.
DIF: Cognitive Level: Understand REF: 512
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

MULTIPLE RESPONSE

1. Which physiologic changes are associated with pregnancy? Select all that apply.
a. Increase in brittleness of fingernails
b. 1500 mL increase in blood volume
c. Periodic shortness of breath later in pregnancy
d. Edematous and bleeding gums
e. Painless vaginal bleeding
f. Waddling gait
ANS: B, C, D, F
Correct: Blood volume increases by 1500 mL to meet the need of an enlarged uterus and fetal tissue, causing increased cardiac workload (increased heart rate). Uterine enlargement pushes up on the diaphragm, causing periodic shortness of breath. Increased estrogen increases vascularity and tissue proliferation of gums, resulting in edematous and bleeding gums. The increased size of the uterus and growing fetus results in the center of gravity moving forward, resulting in a waddling gait.
Incorrect: Increased nail growth is reported by some individuals. Painless vaginal bleeding indicates a problem with the pregnancy, such as placenta previa.

DIF: Cognitive Level: Understand REF: 496
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

2. What does a nurse teach pregnant patients about the effects of smoking while pregnant? Select all that apply.
a. Fluid retention increases.
b. Prematurity risk increases.
c. Low infant birth weight risk increases.
d. Anemia develops.
e. Vitamin C deficiency develops.
f. Craving of starch, baking soda, or clay develops.
ANS: B, C, E
Correct: These three are due to the effects of smoking while pregnant.
Incorrect: Fluid retention increases may occur during pregnancy, but it is not caused by smoking. Anemia may occur during pregnancy, but it is not caused by smoking. Craving of starch, baking soda, or clay may occur during pregnancy, but it is not caused by smoking.

DIF: Cognitive Level: Understand REF: 498
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

3. What manifestations does a nurse anticipate when assessing a patient with preeclampsia? Select all that apply.
a. Systolic blood pressure greater than 140 mm Hg
b. Increase in systolic blood pressure of 20 mm Hg over baseline
c. Diastolic blood pressure greater than 90 mm Hg
d. Increase in diastolic blood pressure of 15 mm Hg over baseline
e. 2 lb increase in weight in 1 week
f. 9 lb increase in weight in 1 month
ANS: A, C, D, F
Correct: Preeclampsia is precipitated by pregnancy-induced hypertension indicated by systolic blood pressure of 140 mm Hg or higher, diastolic blood pressure more than 90 mm Hg, and an increase of more than 15 mm Hg of diastolic blood pressure from baseline. A 9-lb weight gain in this time period contributes to hypertension.
Incorrect: Increase in systolic blood pressure of 20 mm Hg over baseline is an increase of more than 30 mm Hg of systolic blood pressure from baseline. Two-pound increase in weight in 1 week is an expected weight gain during pregnancy.

DIF: Cognitive Level: Understand REF: 513
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

COMPLETION

1. If a patients last menstrual period was May 13, her estimated date of birth is ________.

ANS:
February 20
May 13 minus 3 months = February 13 plus 7 days = February 20.

DIF: Cognitive Level: Apply REF: 497
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

2. A pregnant patients weight before pregnancy was 148 lb. Her expected weight during the first trimester is _____ to _____ lb.

ANS:
151
153
151, 153
3- to 5-lb weight gain is expected during the first trimester resulting in a total of 151 to 153 lb.

DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

3. A pregnant patients weight before pregnancy was 163 lb. The nurse expects the patient to weigh _____ to _____ lb during the second trimester.

ANS:
178; 183
178, 178
A 3- to 5-lb weight gain is expected during the first trimester, making the weight 166 to 168. The second trimester is 12 to 15 lb in addition to the first trimester weight. Thus 166 + 12 lb = 178 lb at the low end and 168 + 15 lb = 183 at the high end.

DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Leave a Reply