Exam 1 - Chapter 28 / REVIEW FOR EXAM 2/3

Question 1

A pregnant woman is being discharged from the hospital after the placement of a cervical
cerclage because of a history of recurrent pregnancy loss, secondary to an incompetent cervix.
Which information regarding postprocedural care should the nurse emphasize in the discharge
teaching?
a. Any vaginal discharge should be immediately reported to her health care provider.
b. The presence of any contractions, rupture of membranes (ROM), or severe perineal
pressure should be reported.
c. The client will need to make arrangements for care at home, because her activity level
will be restricted.
d. The client will be scheduled for a cesarean birth.

Answer 1

B - Nursing care should stress the importance of monitoring for the signs and symptoms of preterm
labor. Vaginal bleeding needs to be reported to her primary health care provider. Bed rest is an
element of care. However, the woman may stand for periods of up to 90 minutes, which allows
her the freedom to see her physician.

Question 2

A perinatal nurse is giving discharge instructions to a woman, status post suction, and
curettage secondary to a hydatidiform mole. The woman asks why she must take oral
contraceptives for the next 12 months. What is the best response by the nurse?
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, then 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, not getting
pregnant at this time is best.
d. Oral contraceptives are theonly form of birth control that will prevent a recurrence of a
molar pregnancy.

Answer 2

B - Betahuman chorionic gonadotropin (beta-hCG) hormone levels are drawn for 1 year to ensure
that themole is completely gone. Thechance of developing choriocarcinoma after
thedevelopment of a hydatidiform mole is increased. Therefore, thegoal is to achieve a zero
human chorionic gonadotropin (hCG) level. If thewoman were to become pregnant, then it may
obscure thepresence of thepotentially carcinogenic cells. Women should be instructed to use
birth control for 1 year after treatment for a hydatidiform mole.

Question 3

Thenurse is preparing to administer methotrexate to theclient. This hazardous drug is
most
often used for which obstetric complication?
a. Complete hydatidiform mole
b. Missed abortion
c. Unruptured ectopic pregnancy
d. Abruptio placentae

Answer 3

C - Methotrexate is an effective nonsurgical treatment option for a hemodynamically stable woman
whose ectopic pregnancy is unruptured and measures less than 4 cm in diameter. Methotrexate is
not indicated or recommended as a treatment option for a complete hydatidiform mole, for a
missed abortion, or for abruptio placentae

Question 4

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, which diagnostic
procedure will the client most likely have performed?
a. Amniocentesis for fetal lung maturity
b. Transvaginal ultrasound for placental location
c. Contraction stress test (CST)
d. Internal fetal monitoring

Answer 4

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

Question 5

A laboring woman with no known risk factors suddenly experiences spontaneous ROM.
The fluid consists of bright red blood. Her contractions are consistent with her current stage of
labor. No change in uterine resting tone has occurred. The fetal heart rate (FHR) begins to decline
rapidly after the ROM. The nurse should suspect the possibility of what condition?
a. Placenta previa
b. Vasa previa
c. Severe abruptio placentae
d. Disseminated intravascular coagulation (DIC)

Answer 5

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. The umbilical blood vessels thus
are at risk for laceration at any time, but laceration occurs most frequently during ROM.

Question 6

A woman arrives for evaluation of signs and symptoms that include a missed period,
adnexal fullness, tenderness, and dark red vaginal bleeding. On examination, the nurse notices an
ecchymotic blueness around the womans umbilicus. What does this finding indicate?
a. Normal integumentary changes associated with pregnancy
b. Turner sign associated with appendicitis
c. Cullen sign associated with a ruptured ectopic pregnancy
d. Chadwick sign associated with early pregnancy

Answer 6

C - Cullen sign, theblue ecchymosis observed in theumbilical area, indicates hematoperitoneum
associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the
abdomen is thenormal integumentary change associated with pregnancy and exhibits a brown
pigmented, vertical line on thelower abdomen. Turner sign is ecchymosis in theflank area, often
associated with pancreatitis. A Chadwick sign is a blue-purple cervix that may be seen during or
around theeighth week of pregnancy.

Question 7

The nurse who elects to practice in the area of womens health must have a thorough
understanding of miscarriage. Which statement regarding this condition is most accurate?
a. A miscarriage is a natural pregnancy loss before labor begins.
b. It occurs in fewer than 5% of all clinically recognized pregnancies.
c. Careless maternal behavior, such as poor nutrition or excessive exercise, can be a factor
in causing a miscarriage.
d. If a miscarriage occurs before the12th week of pregnancy, then it may be observed only
as moderate discomfort and blood loss.

Answer 7

D - Before the sixth week, the only evidence might be a heavy menstrual flow. After the12th week,
more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but it
occurs, by definition, before 20 weeks of gestation, before the fetus is viable. Miscarriages occur
in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriages can be
caused by a number of disorders or illnesses outside the mothers control or knowledge.

Question 8

A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which
differential diagnosis would not fit this client?
a. Placenta previa
b. Abruptio placentae
c. Spontaneous abortion
d. Cord insertion

Answer 8

C - Spontaneous abortion is another name for miscarriage; it occurs, by definition, early in
pregnancy. Placenta previa is a well-known reason for bleeding late in pregnancy. Thepremature
separation of theplacenta (abruptio placentae) is a bleeding disorder that can occur late in
pregnancy. Cord insertion may cause a bleeding disorder that can also occur late in pregnancy.

Question 9

With regard to hemorrhagic complications that may occur during pregnancy, what
information is most accurate?
a. An incompetent cervix is usually not diagnosed until the woman has lost one or two
pregnancies.
b. Incidences of ectopic pregnancy are declining as a result of improved diagnostic
techniques.
c. One ectopic pregnancy does not affect a womans fertility or her likelihood of having a
normal pregnancy the next time.
d. Gestational trophoblastic neoplasia (GTN) is one of the persistently incurable gynecologic
malignancies.

Answer 9

A - Short labors and recurring losses of pregnancy at progressively earlier gestational ages are
characteristics of reduced cervical competence. Because diagnostic technology is improving,
more ectopic pregnancies are being diagnosed. One ectopic pregnancy places thewoman at
increased risk for another one. Ectopic pregnancy is a leading cause of infertility. Once
invariably fatal, GTN now is themost curable gynecologic malignancy.

Question 10

The management of the pregnant client who has experienced a pregnancy loss depends on
the type of miscarriage and the signs and symptoms. While planning care for a client who desires
outpatient management after a first-trimester loss, what would the nurse expect the plan to
include?
a. Dilation and curettage (D&C)
b. Dilation and evacuation (D&E)
c. Misoprostol
d. Ergot products

Answer 10

C - Outpatient management of a first-trimester loss is safely accomplished by theintravaginal use of
misoprostol for up to 2 days. If thebleeding is uncontrollable, vital signs are unstable, or signs of
infection are present, then a surgical evacuation should be performed. D&C is a surgical
procedure that requires dilation of thecervix and scraping of theuterine walls to remove
thecontents of pregnancy. This procedure is commonly performed to treat inevitable or
incomplete abortion and should be performed in a hospital. D&E is usually performed after 16
weeks of pregnancy. Thecervix is widely dilated, followed by removal of thecontents of
theuterus. Ergot products such as Methergine or Hemabate may be administered for excessive
bleeding after miscarriage.

Question 11

Which laboratory marker is indicative of DIC?

a. Bleeding time of 10 minutes
b. Presence of fibrin split products
c. Thrombocytopenia
d. Hypofibrinogenemia

Answer 11

B - Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys
vasculature. Bleeding time in DIC is normal. Low platelets may occur but are not indicative of
DIC because they may be the result from other coagulopathies. Hypofibrinogenemia occurs with
DIC.

Question 12

When is a prophylactic cerclage for an incompetent cervix usually placed (in weeks of

gestation) ?
a. 12 to 14
b. 6 to 8
c. 23 to 24
d. After 24

Answer 12

A - A prophylactic cerclage is usually placed at 12 to 14 weeks of gestation. Thecerclage is
electively removed when thewoman reaches 37 weeks of gestation or when her labor begins. Six
to 8 weeks of gestation is too early to place thecerclage. Cerclage placement is offered if
thecervical length falls to less than 20 to 25 mm before 23 to 24 weeks. Although no consensus
has been reached, 24 weeks is used as the upper gestational age limit for cerclage placement

Question 13

In caring for an immediate postpartum client, the nurse notes petechiae and oozing from
her intravenous (IV) site. The client would be closely monitored for which clotting disorder?
a. DIC
b. Amniotic fluid embolism (AFE)
c. Hemorrhage
d. HELLP syndrome

Answer 13

A - Thediagnosis of DIC is made according to clinical findings and laboratory markers. A physical
examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on
thewomans arm. Excessive bleeding may occur from thesite 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 thepostpartum 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 syndrome is not a clotting disorder, but it may
contribute to theclotting disorder DIC.

Question 14

In caring for the woman with DIC, which 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

Answer 14

A - Primary medical management in all cases of DIC involves a correction of theunderlying cause,
volume replacement, blood component therapy, optimization of oxygenation and perfusion
status, and continued reassessment of laboratory parameters. Central monitoring would not be
initially ordered in a client with DIC because it could contribute to more areas of bleeding.

Question 15

A woman arrives at 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
b. Inevitable
c. Threatened
d. Septic

Answer 15

C - A woman with a threatened abortion has spotting, mild cramps, and no cervical dilation. A
woman with an incomplete abortion would have heavy bleeding, mild-to-severe cramping, and
cervical dilation. An inevitable abortion demonstrates thesame symptoms as an incomplete
abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic
abortion has malodorous bleeding and typically a dilated cervix

Question 16

In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio
placentae?
a. Bleeding
b. Intense abdominal pain
c. Uterine activity
d. Cramping

Answer 16

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

Question 17

Which maternal condition always necessitates delivery by cesarean birth?

a. Marginal placenta previa
b. Complete placenta previa
c. Ectopic pregnancy
d. Eclampsia

Answer 17

B - In complete placenta previa, theplacenta completely covers the cervical os. A cesarean birth is
the acceptable method of delivery. The risk of fetal death occurring is due to preterm birth. If
the previa is marginal (i.e., 2 cm or greater away from the cervical os), then labor can be
attempted. A cesarean birth is not indicated for an ectopic pregnancy. Labor can be safely
induced if the eclampsia is under control.

Question 18

What is the correct definition of a spontaneous termination of a pregnancy (abortion)?

a. Pregnancy is less than 20 weeks.
b. Fetus weighs less than 1000 g.
c. Products of conception are passed intact.
d. No evidence exists of intrauterine infection.

Answer 18

A - An abortion is thetermination of pregnancy before theage of viability (20 weeks). Theweight of
thefetus is not considered because some older fetuses may have a low birth weight. A
spontaneous abortion may be complete or incomplete and may be caused by many problems, one
being intrauterine infection

Question 19

What is the correct terminology for an abortion in which the fetus dies but is retained 
within the uterus?
a. Inevitable abortion
b. Missed abortion
c. Incomplete abortion
d. Threatened abortion

Answer 19

B - Missed abortion refers to the 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 no cervical dilation

Question 20

What condition indicates concealed hemorrhage when the client experiences abruptio 
placentae?
a. Decrease in abdominal pain
b. Bradycardia
c. Hard, board like abdomen
d. Decrease in fundal height

Answer 20

C - Concealed hemorrhage occurs when theedges of theplacenta do not separate. Theformation of a
hematoma behind theplacenta and subsequent infiltration of theblood into theuterine muscle
results in a very firm, boardlike abdomen. Abdominal pain may increase. Theclient will have
shock symptoms that include tachycardia. As bleeding occurs, thefundal height increases.

Question 21

What is thehighest priority nursing intervention when admitting a pregnant woman who
has experienced a bleeding episode in late pregnancy?
a. Assessing FHR and maternal vital signs
b. Performing a venipuncture for hemoglobin and hematocrit levels
c. Placing clean disposable pads to collect any drainage
d. Monitoring uterine contractions

Answer 21

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
the well-being of both the mother and the fetus. The blood levels can be obtained later. Assessing
future bleeding is important; however, the top priority remains mother/fetal well-being.
Monitoring uterine contractions is important but not a top priority.

Question 22

Which order should the nurse expect for a client admitted with a threatened abortion?

a. Bed rest
b. Administration of ritodrine IV
c. Nothing by mouth (nil per os [NPO])
d. Narcotic analgesia every 3 hours, as needed

Answer 22

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. Having the woman
placed on NPO is unnecessary. At times, dehydration may produce contractions; therefore,
hydration is important. Narcotic analgesia will not decrease the contractions and may mask
the severity of the contractions.

Question 23

Which finding on a prenatal visit at 10 weeks of gestation might 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

Answer 23

C - Theuterus in a hydatidiform molar pregnancy is often larger than would be expected on thebasis
of theduration of thepregnancy. Nausea increases in a molar pregnancy because of theincreased
production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced
hypertension. In the clients history, bleeding is normally described as brownish

Question 24

A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Which
information assists the nurse in developing the plan of care?
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 primary concern.

Answer 24

D - Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove
the pregnancy before rupture to prevent hemorrhaging. If the tube must be removed, then
the womans fertility will decrease; however, she will not be infertile. A D&C is performed on
the inside of the uterine cavity. The ectopic pregnancy is located within the tubes

Question 25

A client who has undergone a D&C for early pregnancy loss is likely to be discharged
the same day. The nurse must ensure that her vital signs are stable, that bleeding has been
controlled, and that the woman has adequately recovered from the administration of anesthesia.
To promote an optimal recovery, what information should discharge teaching include? (Select all
that apply.)
a. Iron supplementation
b. Resumption of intercourse at 6 weeks post procedure
c. Referral to a support group, if necessary
d. Expectation of heavy bleeding for at least 2 weeks
e. Emphasizing theneed for rest

Answer 25

A,C,E - Thewoman should be advised to consume a diet high in iron and protein. For many women, iron
supplementation also is necessary. Thenurse should acknowledge that theclient has experienced a
loss, however 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 theneed for rest. Nothing should be placed in thevagina for 2 weeks
after theprocedure, including tampons and vaginal intercourse. Thepurpose of this
recommendation is to prevent infection.

Question 26

Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage.
What are possible causes of early miscarriage? (Select all that apply.)
a. Chromosomal abnormalities
b. Infections
c. Endocrine imbalance
d. Systemic disorders
e. Varicella

Answer 26

A,C,D,E - Infections are not a common cause of early miscarriage. At least 50% of pregnancy losses result
from chromosomal abnormalities. Endocrine imbalances such as hypothyroidism or diabetes are
also possible causes for early pregnancy loss. Other systemic disorders that may contribute to
pregnancy loss include lupus and genetic conditions. Although infections are not a common
cause of early miscarriage, varicella infection in thefirst trimester has been associated with
pregnancy loss.

Question 27

Thereported incidence of ectopic pregnancy has steadily risen over the past 2 decades.
Causes include the increase in sexually transmitted infections (STIs) 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 suspects that a client has early signs of ectopic
pregnancy. The nurse should be observing the client for which signs or symptoms? (Select all that
apply.)
a. Pelvic pain
b. Abdominal pain
c. Unanticipated heavy bleeding
d. Vaginal spotting or light bleeding
e. Missed period

Answer 27

A,B,D,E - A missed period or spotting can be easily mistaken by the client as an early sign 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 client often exhibits severe pain accompanied by
intraabdominal hemorrhage, which may progress to hypovolemic shock with minimal or even no
external bleeding. In approximately one half of women, shoulder and neck pain results from
irritation of the diaphragm from the hemorrhage.