Pregnancy

Question 1

Few pregnant patients actually deliver on their due dates. Why is a due date established?

Answer 1

To assess fetal growt
Establishing a due date is essential to assess fetal growth. Accurate dating is also critical so that screening tests may be done at the appropriate time. If a screening test is supposed to take place at 20 weeks, and it is done too early, the opportunity to identify an abnormality may be missed. In the U.S., if a last menstrual period (LMP) cannot be established, and in women with irregular menses, an ultrasound should be performed.

Question 2

Immunizations are not routinely given during the first trimester of pregnancy. Which immunization(s) may be safely given during the first trimester of pregnancy?

Answer 2

Tetanus, diphtheria and influenza
These immunizations should be given during the first trimester if needed by the pregnant patient. Live viruses should not be given during pregnancy. Therefore, MMR (which is really attenuated, but still considered live) and varicella should never be given to a patient known to be pregnant. There are no specific risks associated with pneumococcus and it appears to be safe when given in the second and third trimesters. There is no pregnancy information for hepatitis A or B immunizations, but the general recommendation is to avoid these during pregnancy unless the patient is particularly at risk for hepatitis

Question 3

A female who is being counseled preconceptually is found to have a negative rubella titer. She should be told if she is vaccinated at this time that pregnancy should be avoided for:

Answer 3

1 month
Women should be advised to avoid pregnancy for 28 days after immunization with MMR. CDC has collected data on women who have accidentally received the immunization while pregnant and there has been no documented injury to offspring. The vaccine is safe for women who are breastfeeding even though the rubella virus is excreted in breast milk. It is safe for young children to be immunized with MMR because infection is not transmitted from immunized people.

Question 4

A pregnant patient asks why she must take calcium during pregnancy. The nurse practitioner replies that:

Answer 4

it will strengthen the bones and teeth in your fetus.
Calcium supplementation during pregnancy is for the fetus, not the pregnant mother. Calcium supplementation will provide extra calcium that is needed during fetal development. It is hypothesized that adequate amounts of calcium will reduce the risk of pregnancy-induced hypertension. Generally, 1000 mg daily is recommended.

Question 5

A pregnant patient with urinary frequency is found to have a UTI. What drug is safest to treat this?

Answer 5

Macrodantin
Medication safety during pregnancy is of utmost concern. Therefore, medications are rated according to safety for the developing fetus. In the current rating system, Macrodantin is the safest and most efficacious medication listed. Amoxicillin is as safe as Macrodantin, but, has a lower efficacy against typical urinary tract pathogens. Doxycycline is associated with fetal tooth discoloration and so it should be avoided. Ciprofloxacin is not recommended during pregnancy due to potential problems with bone and cartilage formation.

Question 6

A patient has a positive pregnancy test that she performed from an over the counter kit. What are the chances that she is pregnant?

Answer 6

> 90%
The over the counter urine pregnancy kits have very high sensitivity and specificity. Consequently, their results can be trusted. A positive urine tests will correlate with the serum results. The tests identify hCG in the specimen.

Question 7

Which factor listed below increases the risk of ectopic pregnancy?

Answer 7

Prior history of ectopic pregnancy
In an ectopic pregnancy, the developing embryo becomes implanted outside the uterus. A common site is the fallopian tube. Young age is a low risk factor for ectopic pregnancy. A past history of ectopic pregnancy confers a high risk of future ectopic pregnancies. Other high risk factors are previous tubal surgery or pathology, tubal ligation, and in utero DES exposure.

Question 8

A patient with an ectopic pregnancy:

Answer 8

will have a positive pregnancy test
A patient with an ectopic pregnancy has a fertilized embryo that is developing outside the uterus. The fallopian tube is the most common location. If detected and managed early, a fallopian tube rupture does not have to occur. She will have a positive pregnancy test about 10 days after fertilization.

Question 9

Immunizations are not routinely given during the first trimester of pregnancy. Besides influenza immunization, which immunization(s) may be safely given during the first trimester of pregnancy?

Answer 9

Td only
These immunizations should be given during the first trimester if needed by the pregnant patient. Live viruses should not be given during pregnancy. Therefore, MMR (which is really attenuated, but still considered live) and varicella should never be given to a patient known to be pregnant. There are no specific risks associated with pneumococcus and it appears to be safe when given in the second and third trimesters. There is no pregnancy information for hepatitis A or B immunizations, but, the general recommendation is to avoid these during pregnancy unless the patient is particularly at risk for hepatitis.

Question 10

Ultrasounds are commonly performed during pregnancy because they:

Answer 10

identify fetal malformations.
Ultrasounds are excellent tools for identifying fetal malformations. They are helpful in detecting multiple fetuses, status of the placenta, and help assess gestational age. While it may be argued that ultrasound use improves outcomes in the fetus or mother, this is not why they are commonly performed during pregnancy. There is no evidence that performing an ultrasound early in pregnancy eliminates or reduces the need for ultrasounds later in pregnancy.

Question 11

All of the factors listed below increase the risk of ectopic pregnancy. Which one confers the lowest risk?

Answer 11

Prior history of ectopic pregnancy
IUD use
History of PID

Young age
In an ectopic pregnancy, the developing embryo becomes implanted outside the uterus. A common site is the fallopian tube. Young age is a low risk factor for ectopic pregnancy. The other choices all confer high risk of ectopic pregnancy. Other high risk factors are previous tubal surgery or pathology, tubal ligation and in utero DES exposure.

Question 12

In a viable pregnancy:

Answer 12

fetal heart tones are audible at about 9-12 weeks.
Fetal heart tones can be heard as early as 9-12 weeks if a Doppler is used. Transvaginal ultrasound can identify movement of the heart at 5-6 weeks.

Question 13

A 24 year-old pregnant patient is being screened with a TSH.The most likely reason for this is because:

Answer 13

she has hypothyroidism.
Routine screening for hypothyroidism is not performed during pregnancy. The ACOG (American College of Obstetricians and Gynecologists) recommends screening when a patient has a personal history of hypothyroidism, family history or is symptomatic. ACOG also recommends screening if another disease is present which is associated with thyroid dysfunction like gestational diabetes.

Question 14

HIV testing during pregnancy:

Answer 14

is recommended by ACOG.
ACOG, the American College of Obstetrics and Gynecology, recommends an “opt-out” approach to HIV screening in pregnant patients. “Opt-out” means that HIV will be routinely performed unless the patient “opts-out”. This practice has improved screening in pregnant patients and increased early intervention for HIV.

Question 15

Hyperemesis gravidarum is:

Answer 15

persistent, intractable vomiting during pregnancy.
Hyperemesis gravidarum (HEG) is a severe form of nausea and vomiting which occurs during pregnancy. In contrast, morning sickness is milder. A common definition used to define HEG is persistent vomiting which produces a weight loss exceeding 5 percent of pre-pregnancy body weight. The etiology of morning sickness and HEG is unknown.

Question 16

You have been asked to evaluate a heart murmur in a pregnant patient. Can a 3D echocardiogram be safely used to evaluate her?

Answer 16

Yes, this is perfectly safe.
An echocardiogram is the best test to evaluate a heart murmur whether the patient is pregnant or not. Echocardiography can be used safely in this patient because no radiation is emitted from 3D echo. The most common murmur in pregnant women is a venous hum murmur. It resolves within several weeks after delivery. It is harmless.

Question 17

A pregnant patient in her first trimester is found to have Chlamydia. How should this be managed?

Answer 17

Treat with azithromycin
Chlamydia is treated in a pregnant patient exactly as it is treated in a non-pregnant patient. Azithromycin is given as a one gram dose. This patient should be screened for other STDs now, and all STDs again before delivery. Commonly, pregnant patients infected with an STD become re-infected before delivery.

Question 18

Nagele’s rule estimates:

Answer 18

estimates date of confinement (EDC).
In determining the due date (EDC), subtract 3 months from the last menstrual period, add 7 days and one year. This estimates the pregnant patient’s due date. While fewer than 10% of pregnant patients actually deliver on their due date, the estimation is important to determine the timing of screening interventions.

Question 19

The rubella vaccine is contraindicated in pregnant women because:

Answer 19

it can cause rubella in the infant.
The rubella vaccine is contraindicated in pregnant patients because it crosses the placenta. Pregnant women should be advised to avoid pregnancy for 28 days after immunization with MMR. It should not be given during pregnancy. However, CDC has collected data on women who have accidentally received the immunization while pregnant and there has been no documented injury to the offspring. The vaccine is safe for women who are breastfeeding even though the rubella virus is excreted in breast milk.

Question 20

A patient was diagnosed today with pregnancy. Her last pregnancy was 3 years ago. At that time she had a protective rubella titer. What should be done about evaluating a rubella titer today?

Answer 20

She does not need one because it was protective 3 years ago.
Explanation:
Standard practice across the United States is to insure that a protective rubella titer exists in women who are pregnant now. If a pregnant patient had a protective rubella titer in a previous pregnancy, re-evaluation is not necessary. A protective titer is usually 1:10 or greater. If she was found at any time during pregnancy to have a negative rubella titer, she should be vaccinated AFTER she delivers this fetus.

Question 21

The need for thyroid replacement during pregnancy:

Answer 21

increases.
Thyroid hormone needs in pregnant patients with a history of hypothyroidism increase during pregnancy. This occurs in nearly 80 percent of pregnant hypothyroid women. Since low circulating thyroid hormone can drastically affect growth, TSH levels should be monitored frequently. Needs can increase by up to 50 percent.

Question 22

A patient who is found to be pregnant has asymptomatic bacteriuria.How should this be managed?

Answer 22

Prescribe nitrofurantoin
A pregnant patient with asymptomatic bacteriuria should be treated with an antibiotic because she is at high risk of developing pyelonephritis. Ciprofloxacin is a quinolone antibiotic. This medication class should be avoided during pregnancy. Amoxicillin is safe to use during pregnancy but has poor coverage of the most likely pathogen which is E. coli. Nitrofurantoin is safe for use during pregnancy and has very good coverage of most urinary tract pathogens.

Question 23

The classic presentation of placenta previa is:

Answer 23

painless vaginal bleeding after the 20th week.
Painless vaginal bleeding occurs after the 20th week. Bleeding is likely at this time because the lower uterine segment develops and uterine contractions occur. At this time, the cervix dilates and effaces. The placenta can become detached and bleeding can occur. In women who are identified to have placenta previa, coitus and vaginal exam are contraindicated because both can cause separation and further bleeding.

Question 24

A pregnant patient is found to have positive leukocytes and positive nitrites in her urine. What medication should be given?

Answer 24

Nitrofurantoin
Explanation:
Nitrofurantoin would be a good choice to treat a UTI in a pregnant patient because it has good coverage of common urinary tract pathogens and it has a pregnancy Category B rating. Doxycycline is a category D; TMPS is a category C; and ciprofloxacin is a category C.

Question 25

hen do the clinical manifestations of an ectopic (fallopian tube) pregnancy typically appear?

Answer 25

6-8 weeks after the LMP
Clinical manifestations usually occur 6-8 weeks after the last menstrual period. The classic symptoms are vaginal bleeding, abdominal pain, and amenorrhea. If shoulder pain accompanies these symptoms, fallopian tube rupture must be considered. The risk of maternal morbidity is increased.

Question 26

In order to establish pregnancy, a pregnancy test of the urine or blood is routinely performed.How early can this be done with predictable results:

Answer 26

1-2 weeks after conception.
Whether performed on urine or blood, the presence of the beta subunit of human chorionic gonadotropin (hCG) is evaluated to identify pregnancy. This can be found in high quantities in the first morning urine or at any time in a serum sample of a pregnant woman. Both tests are highly sensitive, however, if the pregnancy is very early and a first morning urine is NOT used, the urine test may be negative in a pregnant woman. In this instance, the serum specimen will indicate pregnancy.

Question 27

Naegele’s rule is calculated by adding 7 days to the last menstrual period and

Answer 27

substracting 3 months.
Explanation:
Naegele’s rule is an accepted means of predicting gestational age of the fetus. This is based on an average length of pregnancy of 280 days. If the maternal history is not reliable, ultrasound becomes the standard.

Question 28

Most hypertension in pre-adolescents and children is:

Answer 28

secondary hypertension.
Explanation:
Most hypertension in children and pre-adolescents is secondary hypertension. 60-70 percent is due to renal parenchymal disease. Rarely does primary hypertension exist in this age group. However, 85-90 percent of adolescents have primary hypertension. General obesity is often associated with hypertension but is not the primary cause.

Question 29

A patient in her first trimester of pregnancy is found to have gonorrhea. Which statement below is true?

Answer 29

She should be treated now for gonorrhea and chlamydia.
Explanation:
She should be treated for chlamydia and gonorrhea now. Gonorrhea and chlamydia are found concurrently so often, that chlamydia is always treated when gonorrhea is identified. There is no danger with teratogenicity if standard treatment for these two STDs is employed. Since the percentage of patients who become re-infected with an STD later in pregnancy (even after being treated and educated) is very high, this patient should be re-screened later in pregnancy regardless of whether symptoms emerge. Deleterious effects can occur if she is left untreated.

Question 30

Benazepril should be discontinued immediately if:

Answer 30

pregnancy occurs.
Explanation:
Benazepril is an ACE inhibitor and this class of drugs is contraindicated during pregnancy because of the teratogenic effects to the renal system of the developing fetus. Dry cough is an aggravating side effect that occurs in some patients who take ACE inhibitors, but discontinuation is elective. ACE inhibitor use is associated with increased potassium levels not decreased levels. Gout is not exacerbated by ACE inhibitor use.

Question 31

A patient has a positive pregnancy test that she performed from an over the counter kit. She performed it again the next day. It was positive. What are the chances that a serum pregnancy test will be negative?

Answer 31

Almost none
Explanation:
The over the counter urine pregnancy kits have very high sensitivity and specificity. Consequently, their results can be trusted. Two positive urine tests certainly will correlate with the serum results. The tests identify hCG in the specimen.

Question 32

Routine screening for gestational diabetes:

Answer 32

at about 24 weeks.
Explanation:
If a pregnant mother has been diagnosed with diabetes prior to pregnancy, there is no need to screen for gestational diabetes. The routine time for screening is at 24-28 weeks. This has been identified as the ideal time because she is more likely to exhibit elevations in glucose at 24-28 weeks due to placental hormones that increase insulin insensitivity. This is also a good time to initiate interventions that will decrease complications in the fetus associated with glucose elevations. If the pregnant patient has risk factors for diabetes, she can be screened earlier in pregnancy and again at 24-28 weeks.

Question 33

The NP suspects that a pregnant patient may be the victim of domestic violence.The NP knows that:

Answer 33

abuse can accelerate during pregnancy.

Explanation:
The incidence of abuse during pregnancy ranges between 7-20 percent and is higher when pregnancies are unplanned. This percentage is higher than gestational diabetes and pre-eclampsia. Screening is routinely performed for these 2 conditions. Domestic violence often begins during pregnancy and can accelerate when it has existed prior to pregnancy. Therefore, it is important to screen. Unfortunately, this is not reportable in all 50 states.

Question 34

A 17 year-old female is found to be pregnant. What is the LEAST likely risk to her fetus?

Answer 34

Down Syndrome

Explanation:
Routine prenatal screening is important for all pregnant women. Based on her age and the likelihood of multiple partners, she should be screened for STDs to include HIV and hepatitis B and C and chlamydia. Down syndrome is more likely in older pregnant women. Toxoplasmosis is contracted after exposure to feces of cats and undercooked meats.

Question 35

The most effective way to decrease the incidence of neural tube defects in pregnant patients is to:

Answer 35

increase folic acid.
Explanation:
Folic acid has been found to drastically decrease the incidence of neural tube defects (NTD). Folate plays an essential role in synthesis of amino acids and DNA. Since these are critical in cell division and adequate amounts should be on board when cell division begins, folic acid should be taken pre-conceptually. Since this is the second most common congenital anomaly, folic acid should be initiated pre-conceptually.

Question 36

Routine screening for gestational diabetes:

Answer 36

at about 24 weeks.

Explanation:
If a pregnant mother has been diagnosed with diabetes prior to pregnancy, there is no need to screen for gestational diabetes. The routine time for screening is at 24-28 weeks. This has been identified as the ideal time because she is more likely to exhibit elevations in glucose at 24-28 weeks due to placental hormones which increase insulin insensitivity. This is also a good time to initiate interventions that will decrease complications in the fetus associated with glucose elevations. If the pregnant patient has risk factors for diabetes, she can be screened earlier in pregnancy and again at 24-28 weeks.

Question 37

Ultrasounds are commonly performed during the first trimester of pregnancy because they help estimate gestational age and:

Answer 37

identify fetal malformations.

Explanation:
Ultrasounds are excellent tools in the first trimester of pregnancy because they can help identify fetal malformations. They are helpful in detecting multiple fetuses, status of the placenta, and help assess gestational age. While it may be argued that ultrasound use improves outcomes in the fetus or mother, this is not why they are commonly performed during the first trimester. There is no evidence that performing an ultrasound early in pregnancy eliminates or reduces the need for ultrasounds later in pregnancy.

Question 38

A pregnant patient asks if sexual activity will place her fetus at any increased risk. The nurse practitioner responds:

Answer 38

this may increase the risk of pre-term labor.

Explanation:
Sexual activity during pregnancy could cause exposure to an STD or precipitate pre-term labor because the lower uterine segment may be physically stimulated. Additionally, oxytocin is released which may precipitate pre-term labor. In the absence of complications associated with the pregnancy, sexual activity is not contraindicated. If vaginal discharge or bleeding occurs; or rupture of membranes occurs, sexual intercourse should be avoided until assessed by the patient’s provider. STDs should be screened and treated.

Question 39

A pregnant patient is 30 weeks into her pregnancy.She lives in San Diego and asks whether it will be safe to travel to Denver, Colorado for a hiking trip. The nurse practitioner knows:

Answer 39

travel to a city of high altitude can precipitate preterm labor.

Explanation:
There is no risk for the pregnant patient (prior to 35-36 weeks) who is traveling in an airplane with a pressurized cabin. Travel to a city of moderate or high altitude may impose the risk of preterm labor and bleeding complications. Practically speaking, serious trauma could occur if she falls. Her balance may be compromised at 30 weeks and falling could be likely. In any event, she should have adequate time to acclimate at this higher elevation whether she visits or hikes in Colorado.

Question 40

A patient in her first trimester of pregnancy is found to have chlamydia and gonorrhea. Which statement below is true?

Answer 40

She should be treated now and re-screened later in pregnancy.

Explanation:
She should be treated for Chlamydia and gonorrhea now. There is no danger with teratogenicity if standard treatment for these two STDs is employed. Since the percentage of patients who become re-infected with an STD later in pregnancy (even after being treated and educated) is very high, this patient should be re-screened later in pregnancy regardless of whether symptoms emerge. Deleterious effects can occur if she is left untreated.

Question 41

A 30 year-old with Type 1 diabetes has become pregnant. The routine diabetic screening:

Answer 41

can be eliminated.

Explanation:
If a pregnant mother has been diagnosed with diabetes prior to pregnancy, there is no need to screen for gestational diabetes. The routine time for screening is at 24-28 weeks. This has been identified as the ideal time because she is more likely to exhibit elevations in glucose at 24-28 weeks due to placental hormones that increase insulin insensitivity. This is also a good time to initiate interventions that will decrease complications in the fetus associated with glucose elevations.

Question 42

A pregnant teenager asks if sexual activity is safe during pregnancy. The nurse practitioner responds:

Answer 42

this can expose you to STDs.

Explanation:
Sexual activity during pregnancy could cause exposure to an STD; or precipitate pre-term labor because the lower uterine segment may be physically stimulated. Additionally, oxytocin is released which may precipitate pre-term labor. However, in the absence of complications associated with the pregnancy, sexual activity is not contraindicated. If vaginal discharge or bleeding occurs; or rupture of membranes occurs, sexual intercourse should be avoided until assessed by the patient’s provider. STDs should be screened and treated.

Question 43

A pregnant patient is likely to have:

Answer 43

a venous hum murmur and an S3.

Explanation:
Many changes occur in the cardiovascular system when patients are pregnant. Nearly all pregnant women have a venous hum murmur. A higher basal heart rate, louder heart sounds and a systolic ejection murmur. An S3 is commonly present probably related to increased fluid. An S4 is rarely heard. Mitral stenosis and aortic regurgitation are diastolic murmurs and these are abnormal in pregnant patients.

Question 44

Which form of birth control would be the best choice in a lactating mother who wanted to insure that she did not become pregnant?

Answer 44

Depo-provera

Explanation:
The highest rate of pregnancy prevention occurs with Depo-Provera injections. The rate is about 99.7% prevention. The prevention rate with the progestin only pill is about 97-99%. The theoretical rate of effectiveness with oral contraceptives is 99.7%, but the actual rate is 90-96%. With natural family planning, pregnancy is prevented about 79%.

Question 45

A patient who is found to be pregnant has asymptomatic bacteriuria. What is the likely pathogen?

Answer 45

E. coli

Explanation:
A pregnant patient with asymptomatic bacteriuria should be treated with an antibiotic because she is at high risk of developing pyelonephritis. Nitrofurantoin is safe for use during pregnancy and has very good coverage of the most common urinary tract pathogens, including E. coli.

Question 46

The classic symptoms of an ectopic pregnancy are:

Answer 46

amenorrhea, vaginal bleeding and abdominal pain.

Explanation:
The percentage of patients with ectopic pregnancy report these common symptoms: abdominal pain (99 percent), amenorrhea (74 percent) and vaginal bleeding (56 percent). Classic symptoms of an ectopic pregnancy usually appear 6-8 weeks after the last menstrual period.The usual symptoms of pregnancy are also present. Shoulder pain can be present after the tube has ruptured because blood irritates the diaphragm producing referred pain. Abdominal pain, vaginal discharge and fever should cause the examiner to think of an infection, usually associated with sexually transmitted diseases.

Question 47

In order to establish pregnancy, a pregnancy test of the urine or blood is routinely performed. This test assesses for the presence of:

Answer 47

beta hCG.

Explanation:
Whether performed on urine or blood, the presence of the beta subunit of human chorionic gonadotropin (hCG) is evaluated. This can be found in high quantities in the first morning urine or at any time in a serum sample of a pregnant woman. Both tests are highly sensitive. If the pregnancy is very early and a first morning urine is NOT used, the urine test may be negative in a pregnant woman. In this instance, the serum specimen will indicate pregnancy.