Chapter 10- Anatomy and physiology of pregnancy

Question 1

A patient’s obstetrical history indicates that they are pregnant for the fourth time and all of the children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is this patient’s gravidity and parity using the GTPAL system?
a. 3-1-1-1-3
b. 4-1-3-0-4
c. 3-0-3-0-3
d. 4-2-1-0-3

Answer 1

The correct calculation of this patient’s gravidity and parity is 4-1-3-0-4. Using the GPTAL system, the information is calculated as follows:
G: This, the first number, reflects the total number of times the woman has been pregnant; she is pregnant for the fourth time.
T: This number indicates the number of births at term; only one of her pregnancies has resulted in a fetus at term.
P: This is the number of preterm births; the patient has had two pregnancies in which she delivered 3 infants preterm.
A: This number signifies whether the patient has had any abortions or miscarriages before the period of viability; they have not.
L: This number signifies the number of children born who are currently living; the patient has four children.

Question 2

A patient is 6 weeks pregnant. They have had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is the patient’s obstetrical history using the GTPAL system?
a. 2-0-0-1-1
b. 2-1-0-1-0
c. 3-1-0-1-0

Answer 2

NS: C
The correct calculation of this patient’s gravidity and parity is 3-1-0-1-0.
G: Total number of times the patient has been pregnant (they are pregnant for the third time).
T: Number of pregnancies carried to term (they have had only one pregnancy that resulted in a fetus at term).
P: Number of pregnancies that resulted in a preterm birth (none).
A: Abortions or miscarriages before the period of viability (they have had one).
L: Number of children born who are currently living (they have no living children).

Question 3

Over-the-counter (OTC) pregnancy tests usually rely on which technology to test for human chorionic gonadotropin (hCG)? a. Radioimmunoassay
b. Radioreceptor assay
c. Latex agglutination test
d. Enzyme-linked immunosorbent assay (ELISA)

Answer 3

ANS: D
ELISA technology is used in OTC pregnancy tests for its one-step, accurate results. Radioimmunoassay, radioreceptor assay, and latex agglutination tests are all used to detect hCG at varying times in the early gestational period, but they are not characteristic of OTC pregnancy tests.

Question 4

Which presumptive sign or symptom of pregnancy would a patient at 10 weeks of gestation most likely have? a. Amenorrhea
b. Positive pregnancy test
c. Chadwick sign
d. Hegar sign

Answer 4

ANS: A
Amenorrhea is a presumptive sign of pregnancy. Presumptive signs of pregnancy are those felt by the patient. A positive pregnancy test, the presence of Chadwick sign, and the presence of Hegar sign are probable signs of pregnancy.

Question 5

understanding of the nurse’s instructions if they state which is a positive sign of pregnancy?
a. A positive pregnancy test
b. Fetal movement palpated by the nurse
c. Braxton Hicks contractions
d. Quickening

Answer 5

ANS: B
Positive signs of pregnancy are those attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating fetal movement. A positive pregnancy test and Braxton Hicks contractions would be probable signs of pregnancy. Quickening would be a presumptive sign of pregnancy.

Question 6

A patient is at 14 weeks of gestation. The nurse would expect to palpate the fundus at which level?
a. The fundus is not palpable above the symphysis at this time
b. Slightly above the symphysis pubis
c. At the level of the umbilicus
d. Slightly above the umbilicus

Answer 6

ANS: B
In normal pregnancies the uterus grows at a predictable rate. It may be palpated above the symphysis pubis sometime between the twelfth and fourteenth weeks of pregnancy. As the uterus grows, it may be palpated above the symphysis pubis sometime between the twelfth and fourteenth weeks of pregnancy. The uterus rises gradually to the level of the umbilicus at 22 to 24 weeks of gestation.

Question 7

During a patient’s physical examination a nurse notes that the lower uterine segment is soft on palpation. How would the nurse document this finding?
a. Hegar sign
b. McDonald sign
c. Chadwick sign
d. Goodell sign

Answer 7

ANS: A
At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occur; this is called Hegar sign. McDonald sign indicates a fast food restaurant. Chadwick sign is the blue-violet colouring of the cervix caused by increased vascularity; this occurs around the fourth week of gestation. Softening of the cervical tip is called Goodell sign, which may be observed around the sixth week of pregnancy.

Question 8

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a patient in their second trimester?
a. Less audible heart sounds (S1, S2)
b. Increased pulse rate
c. Increased blood pressure
d. Decreased red blood cell (RBC) production

Answer 8

ANS: B
Between 14 and 20 weeks of gestation the pulse increases about 10 to 15 beats/min, which persists to term. Splitting of S1 and S2 is more audible. In the first trimester blood pressure usually remains the same as at the pre-pregnancy level, but it gradually decreases up to about 20 weeks of gestation. During the second trimester both the systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Production of RBCs accelerates during pregnancy.

Question 9

A number of changes in the integumentary system occur during pregnancy. What change persists after birth?
a. Epulis
b. Chloasma
c. Telangiectasia
d. Striae gravidarum

Answer 9

ANS: D
Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. After birth they usually fade, although they never disappear completely. An epulis is a red, raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead, especially in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasia, or vascular spiders, are tiny, star-shaped or branchlike, slightly raised, pulsating end-arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. These usually disappear after birth.

Question 10

10. The musculoskeletal system adapts to the changes that occur during pregnancy. A pregnant patient can expect to experience which change?
    a. Their centre of gravity will shift backward.
    b. They will have increased lordosis.
    c. They will have increased abdominal muscle tone.
    d. They will notice decreased mobility of their pelvic joints.

Answer 10

ANS: B
An increase in the normal lumbosacral curve (lordosis) develops, and a compensatory curvature in the cervicodorsal region develops to help maintain balance. The centre of gravity shifts forward. They will have decreased muscle tone. They will notice increased mobility of their pelvic joints.

Question 11

A 31-year-old woman believes that she may be pregnant. She took an over-the counter (OTC) pregnancy test 1 week ago after missing her period; the test was positive. During her assessment interview the nurse inquires about the woman’s last menstrual period and asks whether she is taking any medications. The woman states that she takes medicine for epilepsy. She has been under considerable stress lately at work and has not been sleeping well. She also has a history of irregular periods. Her physical examination does not indicate that she is pregnant. She has an ultrasound scan, which reveals that she is not pregnant. What is the most likely cause of the false-positive pregnancy test result?
a. She took the pregnancy test too early.
b. She takes anticonvulsants.
c. She has a fibroid tumour.
d. She has been under considerable stress and has a hormone imbalance.

Answer 11

ANS: B
Anticonvulsants may cause false-positive pregnancy test results. OTC pregnancy tests use enzyme-linked immunosorbent assay technology, which can yield positive results as soon as 4 days after implantation. Implantation occurs 6 to 10 days after conception. If the woman were pregnant, she would be into her third week at this point (having missed her period 1 week ago). Fibroid tumours do not produce hormones and have no bearing on human chorionic gonadotropin (hCG) pregnancy tests. Although stress may interrupt normal hormone cycles (menstrual cycles), it does not affect hCG levels or produce positive pregnancy test results.

Question 12

A patient is in their seventh month of pregnancy. They have been having symptoms of nasal congestion and occasional epistaxis. How should a nurse interpret this concern?
a. This is a normal change in pregnancy caused by elevated levels of estrogen.
b. This is an abnormal cardiovascular alteration as nosebleeds are an ominous sign.
c. They are a victim of domestic violence and is being hit in the face by their partner.
d. They have most likely been using cocaine intranasally.

Answer 12

ANS: A
Elevated levels of estrogen cause capillaries to become engorged in the respiratory tract. This may result in edema in the nose, larynx, trachea, and bronchi. This congestion may cause nasal stuffiness and epistaxis. Cardiovascular changes in pregnancy may cause edema in lower extremities. Determining that the patient is a victim of domestic violence and was hit in the face cannot be made on the basis of the sparse facts provided. If the patient had been hit in the face, they most likely would have additional physical findings. The use of cocaine by the patient cannot be made on the basis of the sparse facts provided.

Question 13

13. Which hormone is essential for maintaining pregnancy?
    a. Estrogen
    b. Human chorionic gonadotropin (hCG)
    c. Oxytocin
    d. Progesterone

Answer 13

ANS: D
Progesterone is essential for maintaining pregnancy; it does so by relaxing smooth muscles. This reduces uterine activity and prevents miscarriage. Estrogen plays a vital role in pregnancy, but it is not the primary hormone for maintaining pregnancy. hCG levels rise at implantation but decline after 60 to 70 days. Oxytocin stimulates uterine contractions.

Question 14

14. Which gastrointestinal change during pregnancy would alert a nurse that a patient requires further assessment?
    a. Ptyalism
    b. Pyrosis
    c. Pica
    d. Decreased peristalsis

Answer 14

NS: C
Pica is a desire to eat nonfood substances. Usually the subjects of these cravings, if consumed in small amounts, are not harmful to the pregnancy if the patient has adequate nutrition with appropriate weight gain; however, if the patient eats large quantities of nonfood items, this can interfere with their appetite, and they may not get appropriate nutrition, thus further assessment is required. Ptyalism (excessive salivation), pyrosis (heartburn), and decreased peristalsis are normal findings.

Question 15

Why may appendicitis be difficult to diagnose in pregnancy?
a. The appendix is displaced upward and laterally, high and to the right.
b. The appendix is displaced upward and laterally, high and to the left.
c. The appendix is deep at McBurney point.
d. The appendix is displaced downward and laterally, low and to the right.

Answer 15

ANS: A
The appendix is displaced high and to the right, beyond McBurney point.

Question 16

What is the term given to a person who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability?
a. Primipara
b. Primigravida
c. Multipara
d. Nulligravida

Answer 16

ANS: A
A primipara is a patient who has completed one pregnancy with a viable fetus. To remember terms, keep the following in mind: gravida is a pregnant patient; para comes from parity, meaning a viable fetus; primi means first; multi means many; and null means none. A primigravida is a patient pregnant for the first time. A multipara is a patient who has completed two or more pregnancies with a viable fetus. A nulligravida is a patient who has never been pregnant.

Question 17

17. Which time-based description of a stage of development in pregnancy is accurate?
    a. Viability—22 to 37 weeks since the last menstrual period (LMP) (assuming a fetal
    weight greater than 500 g)
    b. Term—pregnancy from the beginning of week 37 to the end of week 40 plus 6
    days’ gestation
    c. Preterm—pregnancy from 20 to 28 weeks
    d. Postdate—pregnancy that extends beyond 38 weeks

Answer 17

ANS: B
Term is weeks 37 to 44 plus 6 days gestation. Viability is the ability of the fetus to live outside the uterus before coming to term, or 22 to 24 weeks since LMP. Preterm is 20 weeks but before completion of 37 weeks of gestation. Postdate or postterm is a pregnancy that extends beyond 41 weeks, or what is considered the limit of full term.

Question 18

Human chorionic gonadotropin (hCG) is an important biochemical marker for pregnancy and is thus the basis for many tests. Which should a nurse be aware of in relation to hCG?
a. hCG can be detected as early as 2.5 weeks after conception.
b. hCG level increases gradually and uniformly throughout pregnancy.
c. Much lower than normal increases in the level of hCG may indicate a postdate pregnancy.
d. A higher than normal level of hCG may indicate an ectopic pregnancy or Down syndrome.

Answer 18

ANS: D
Higher levels may indicate an ectopic pregnancy or Down syndrome; as well, it could be a sign of multiple gestation. hCG can be detected as early as 7 to 10 days after conception. The hCG level fluctuates during pregnancy: peaking, declining, stabilizing, and increasing again. Abnormally slow increases may indicate impending miscarriage.

Question 19

19. Which should a nurse be aware of in order to reassure and educate pregnant patients about changes in the uterus during pregnancy?
    a. Lightening occurs near the end of the second trimester as the uterus rises into a
    different position.
    b. The patient’s increased urinary frequency in the first trimester is the result of
    exaggerated uterine anteflexion.
    c. Braxton Hicks contractions become more painful in the third trimester,
    particularly if the patient tries to exercise.
    d. The uterine souffle is the movement of the fetus.

Answer 19

ANS: B
The pregnant patient’s increased urinary frequency in the first trimester is the result of exaggerated uterine anteflexion caused by softening. Lightening occurs in the last 2 to 4 weeks of pregnancy in the primipara patient and near the end of term or start of labour in the multipara patient. Braxton Hicks contractions become more defined in the final trimester but are not painful. Walking or exercise usually causes them to stop. The uterine souffle is the sound made by blood in the uterine arteries; it can be heard with a fetal stethoscope.

Question 20

Which should a nurse be aware of in order to reassure and educate pregnant patients about changes in the cervix, vagina, and position of the fetus during pregnancy?
a. Because of a number of changes in the cervix, abnormal Papanicolaou (Pap) tests
are much easier to evaluate.
b. Quickening is a technique of palpating the fetus to engage it in passive movement.
c. The deepening colour of the vaginal mucosa and cervix (Chadwick sign) usually
appears in the second trimester or later as the vagina prepares to stretch during
labour.
d. Increased vascularity of the vagina increases sensitivity and may lead to a high
degree of arousal, especially in the second trimester

Answer 20

ANS: D
Increased sensitivity and an increased interest in sex sometimes go together. This frequently occurs during the second trimester, related to the increased vascularity of the vagina. Cervical changes make evaluation of abnormal Pap tests more difficult. Quickening is the first recognition of fetal movements by the pregnant patient. Ballottement is a technique used to palpate the fetus. Chadwick sign appears from the sixth to the eighth week.

Question 21

What is the term given to the mucous plug that forms in the endocervical canal?
a. Operculum
b. Leucorrhea
c. Funic souffle
d. Ballottement

Answer 21

ANS: A
The operculum protects against bacterial invasion. Leucorrhea is the mucus that forms the endocervical plug (the operculum). The funic souffle is the sound of blood flowing through the umbilical vessels. Ballottement is a technique for palpating the fetus.

Question 22

Which is important for a nurse to know in order to be able to reassure and educate pregnant patients about changes in their breasts?
a. The visibility of blood vessels that form an intertwining blue network indicates
full function of Montgomery’s tubercles and possibly infection of the tubercles.
b. The mammary glands do not develop until 2 weeks before labour.
c. Lactation is inhibited until the estrogen level declines after birth.
d. Colostrum is the yellowish oily substance used to lubricate the nipples for
breastfeeding.

Answer 22

ANS: C
Lactation is inhibited until after birth. The visible blue network of blood vessels is a normal outgrowth of a richer blood supply. The mammary glands are functionally complete by midpregnancy. Colostrum is a creamy, white-to-yellow premilk fluid that can be expressed from the nipples before birth.

Question 23

23. Which is important for a nurse to know in order to be able to reassure and educate pregnant patients about changes in their cardiovascular system during pregnancy?
    a. A pregnant patient experiencing disturbed cardiac rhythm, such as sinus
    arrhythmia, requires close medical and obstetrical observation.
    b. Changes in heart size and position and increases in blood volume create auditory
    changes from 20 weeks to term.
    c. Palpitations are twice as likely to occur in twin gestations.
    d. Blood pressure increases until about 24 to 32 weeks of gestation.

Answer 23

ANS: B
Changes in heart size and position and increased blood volume lead to auditory changes after 20 weeks of gestation. A healthy patient with no underlying heart disease does not need any therapy. The patient’s heart rate increases in the third trimester, but palpitations may not necessarily occur, let alone double. Blood pressure decreases, not increases, until about 24 to 32 weeks of gestation.

Question 24

Which change in the blood pressure of pregnant patients should a nurse be aware of in order to educate the patient?
a. A blood pressure cuff that is too small produces a reading that is too low; a cuff
that is too large produces a reading that is too high.
b. Shifting the patient’s position and changing from arm to arm for different
measurements produces the most accurate composite blood pressure reading.
c. The systolic blood pressure increases slightly as pregnancy advances; the
diastolic pressure remains constant.
d. Compression of the iliac veins and inferior vena cava by the uterus contributes to
hemorrhoids in the later stage of term pregnancy.

Answer 24

ANS: D
Compression of the iliac veins and inferior vena cava also leads to varicose veins in the legs and vulva. The tightness of a cuff that is too small produces a reading that is too high; similarly, the looseness of a cuff that is too large results in a reading that is too low. Because maternal positioning affects readings, blood pressure measurements should be obtained in the same arm and with the woman in the same position. The systolic blood pressure generally remains constant but may decline slightly as pregnancy advances. The diastolic blood pressure first drops and then gradually increases.

Question 25

Some pregnant patients may state they have changes in their voice and have impaired hearing. To what can the nurse ascribe these common reactions?
a. Decreased estrogen level
b. Displacement of the diaphragm, resulting in abdominal breathing
c. Increased vascularity of the upper respiratory tract
d. Increased blood volume

Answer 25

ANS: C
Estrogen levels increase, causing the upper respiratory tract to become more vascular; this produces swelling and congestion in the nose and ears and thus voice changes and impaired hearing. The diaphragm is displaced, resulting in thoracic breathing rather than abdominal breathing. The volume of blood is increased but has no direct effect on the voice and hearing. Estrogen levels increase, not decrease.

Question 26

Which is important for a nurse to know in order to be able to reassure and educate pregnant patients about the functioning of their kidneys in eliminating waste products during pregnancy?
a. Increased urinary output makes pregnant patients less susceptible to urinary
infection.
b. Increased bladder sensitivity and later compression of the bladder by the
enlarging uterus result in the urge to urinate even if the bladder is almost empty.
c. Renal (kidney) function is more efficient when the patient assumes a supine
position.
d. Using diuretics during pregnancy can help keep kidney function regular.

Answer 26

ANS: B
First bladder sensitivity and then compression of the bladder by the uterus result in the urge to urinate more often. A number of anatomical changes make a pregnant woman more susceptible to urinary tract infection. Renal function is more efficient when the woman lies in the lateral recumbent position and less efficient when she is supine. Diuretic use during pregnancy can overstress the system and cause problems.

Question 27

Which statement about a condition of pregnancy is accurate?
a. Ptyalism is caused by increases in estrogen.
b. Pyrosis begins early but declines throughout pregnancy.
c. Temporary hyperthyroidism often develops because hormone production
increases.
d. Nausea and vomiting rarely have harmful effects on the fetus.

Answer 27

ANS: D
Normal nausea and vomiting rarely produce harmful effects. Ptyalism is excessive salivation, which may be caused by a decrease in unconscious swallowing or stimulation of the salivary glands. Pyrosis begins as early as the first trimester and intensifies through the third trimester. Increased hormone production does not lead to hyperthyroidism in pregnant women.

Question 28

What should a nurse teach a patient in relation to Braxton Hicks contractions?
a. They are painless.
b. They increase with walking.
c. They cause cervical dilation.
d. They impede oxygen flow to the fetus.

Answer 28

ANS: A
Soon after the fourth month of gestation uterine contractions can be felt through the abdominal wall. Braxton Hicks contractions are regular and painless and continue throughout the pregnancy. Although they are not painful, some patients state that they are annoying. Braxton Hicks contractions usually cease with walking or exercise. They can be mistaken for true labour; however, they do not increase in intensity or frequency, nor do they cause cervical dilation. In addition, they facilitate uterine blood flow through the intervillous spaces of the placenta and thereby promote oxygen delivery to the fetus.

Question 29

The diagnosis of pregnancy is based on which positive sign of pregnancy?
a. Positive hCG test
b. Palpation of fetal outline
c. Ballottement
d. Verification of fetal movement

Answer 29

ANS: D
Verification of fetal movement is a positive, objective sign of pregnancy. Palpation of fetal outline, ballottement, and a positive hCG test are probable signs of pregnancy. Palpation of outline is not positive as it may be a tumour that is palpated.

Question 30

30. A patient is in for a routine prenatal checkup. A nurse is assessing their urinary system. Which finding is considered abnormal?
    a. Decreased blood urea nitrogen (BUN)
    b. Increased glomerular filtration rate (GFR)
    c. Increased bladder capacity
    d. Increased proteinuria

Answer 30

ANS: D
Proteinuria does not usually occur in normal pregnancy, it may indicate renal problems; the patient needs to be further assessed to ensure that they are not also hypertensive. BUN is normally decreased in pregnancy. GFR is normally increased in pregnancy. A pregnant patient’s bladder capacity is normally increased in pregnancy.

Question 31

A perinatal nurse understands that vascular volume increases 40% to 45% during pregnancy to
a. compensate for decreased renal plasma flow.
b. provide adequate perfusion of the placenta.
c. eliminate metabolic wastes of the mother.
d. prevent maternal and fetal dehydration.

Answer 31

ANS: B
The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Renal plasma flow increases during pregnancy. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume.

Question 32

Physiological anemia often occurs during pregnancy as a result of
a. inadequate intake of iron.
b. dilution of hemoglobin concentration.
c. the fetus establishing iron stores.
d. decreased production of erythrocytes.

Answer 32

ANS: B
When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the pregnant patient has physiological anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. There is an increased production of erythrocytes during pregnancy.

Question 33

The diagnosis of pregnancy is based on which positive signs of pregnancy? (Select all that apply.)
a. Identification of fetal heartbeat
b. Palpation of fetal outline
c. Visualization of the fetus
d. Verification of fetal movement
e. Positive hCG test

Answer 33

ANS: A, C, D
Identification of fetal heartbeat, visualization of the fetus, and verification of fetal movement are all positive, objective signs of pregnancy. Palpation of fetal outline and a positive hCG test are probable signs of pregnancy. A tumour also can be palpated. Medication and tumours may lead to false-positive results on pregnancy tests.

Question 34

During pregnancy, many changes occur as a direct result of the presence of the fetus. Which of these adaptations meet this criterion? (Select all that apply.)
a. Leukorrhea
b. Development of the operculum
c. Quickening
d. Ballottement
e. Lightening

Answer 34

ANS: C, D, E
Leukorrhea is a white or slightly gray vaginal discharge that develops in response to cervical stimulation by estrogen and progesterone. Quickening is the first recognition of fetal movements or “feeling life.” Quickening is often described as a flutter and is felt earlier in multiparous women than in primiparas. Lightening occurs when the fetus begins to descend into the pelvis. This occurs 2 weeks before labour in the nullipara and at the start of labour in the multipara. Mucus fills the cervical canal creating a plug otherwise known as the operculum. The operculum acts as a barrier against bacterial invasion during the pregnancy. Passive movement of the unengaged fetus is referred to as ballottement.

Question 35

A patient is 6 weeks pregnant. They have had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is the patient’s obstetrical history using the GTPAL system?

Answer 35

ANS: 3-1-0-1-0
The correct calculation of this patient’s obstetrical history is 3-1-0-1-0. Using the GPTAL system, this patient’s gravidity and parity information is calculated as follows:
G: Total number of times the woman has been pregnant (she is pregnant for the third time).
T: Number of pregnancies carried to term (she has had only one pregnancy that resulted in a fetus at term). P: Number of pregnancies that resulted in a preterm birth (none).
A: Abortions or miscarriages before the period of viability (she has had one).
L: Number of children born who are currently living (she has no living children).