TEST 2: Complications of Pregnancy

Question 1

1. A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The
   pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver
   the correct dose, the nurse should set the pump to deliver how many milliliters per hour?
   ___________________________________mL.

Answer 1

The Pregnant Client with Preeclampsia or Eclampsia
1. 50 mL
CN: Pharmacological and parenteral therapies; CL: Apply

Question 2

2. A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks’
   gestation. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and
   feet. What further information should the nurse obtain to determine if this client is becoming
   preeclamptic?
3. Headaches.
4. Blood glucose level.
5. Proteinuria.
6. Edema in lower extremities

Answer 2

2. 3. The two major defining characteristics of preeclampsia are blood pressure elevation of
      140/90 mm Hg or greater and proteinuria. Because the client’s blood pressure meets the gestational
      hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If
      she does not, then she may be having transient hypertension. The edema is within normal limits for
      someone at this gestational age, particularly because it is in the lower extremities. The preeclamptic
      client will have significant edema in the face and hands. Headaches are significant in pregnancy-
      induced hypertension but may have other etiologies. The client’s blood glucose level has no bearing
      on a preeclampsia diagnosis.
      CN: Physiological adaptation; CL: Analyze

Question 3

3. The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to
   determine fetal well-being. Which statement by the client indicates that she needs further instruction
   about when to call the health care provider concerning fetal movement?
4. “If the fetus is becoming less active than before.”
5. “If it takes longer each day for the fetus to move 10 times.”
6. “If the fetus stops moving for 12 hours.”
7. “If the fetus moves more often than 3 times an hour.”

Answer 3

3. 4. The fetus is considered well if it moves more often than 3 times in 1 hour. Daily fetal
      movement counting is part of all high-risk assessments and is a noninvasive, inexpensive method of
      monitoring fetal well-being. The health care provider should be notified if there is a gradual slowing
      over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or
      if the fetus stops moving for 12 hours or longer.
      CN: Reduction of risk potential; CL: Evaluate

Question 4

4. A 29-year-old multigravida at 37 weeks’ gestation is being treated for severe preeclampsia
   and has magnesium sulfate infusing at 3 g/h. To maintain safety for this client, the priority intervention
   is to:
5. Maintain continuous fetal monitoring.
6. Encourage family members to remain at bedside.
7. Assess reflexes, clonus, visual disturbances, and headache.
8. Monitor maternal liver studies every 4 hours.

Answer 4

4. 3. The central nervous system (CNS) functioning and freedom from injury is a priority in
      maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to
      hypertension or stroke, oxygenation status is compromised and the well-being of both mother and
      infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would
      be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate
      fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus,
      visual disturbances, and headache give clear evidence of the condition of the maternal CNS system.
      Monitoring the liver studies does give an indication of the status of the maternal system but the less
      invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal
      headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and
      can be accomplished in ways other than having the family remain at the bedside.
      CN: Safety and infection control; CL: Synthesize

Question 5

5. At 32 weeks’ gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (151.7 cm)
   has gained a total of 20 lb (9.1 kg), with a 1-lb (0.45-kg) gain in the last 2 weeks. Urinalysis reveals
   negative glucose and a trace of protein. The nurse should advise the client that which of the following
   factors increases her risk for preeclampsia?
6. Total weight gain.
7. Short stature.
8. Adolescent age group.
9. Proteinuria.

Answer 5

5. 3. Clients with increased risk for preeclampsia include primigravid clients younger than 20
      years or older than 40 years, clients with five or more pregnancies, women of color, women with
      multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total
      weight gain of 20 lb (9.1 kg) at 32 weeks’ gestation with a 1-lb (0.45-kg) weight gain in the last 2
      weeks is within normal limits. Short stature is not associated with the development of preeclampsia.
      A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+
      or more may be a symptom of pregnancy-induced hypertension.
      CN: Reduction of risk potential; CL: Synthesize

Question 6

6. After instructing a primigravid client at 38 weeks’ gestation about how preeclampsia can affect
   the client and the growing fetus, the nurse realizes that the client needs additional instruction when she
   says that preeclampsia can lead to which of the following?
7. Hydrocephalic infant.2. Abruptio placentae.
8. Intrauterine growth retardation.
9. Poor placental perfusion.

Answer 6

6. 1. Congenital anomalies such as hydrocephalus are not associated with preeclampsia.
      Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth retardation, and
      poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of
      severe vasoconstriction. Intrauterine growth retardation is possible owing to poor placental
      perfusion. Poor placental perfusion results from increased vasoconstriction.
      CN: Physiological adaptation; CL: Evaluate

Question 7

7. After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record
   of fetal movement patterns at home, the nurse determines that the teaching has been effective when the
   client says that she will count the number of times the baby moves during which of the following time
   spans?
8. 30-minute period three times a day.
9. 45-minute period after lunch each day.
10. 1-hour period each day.
11. 12-hour period each week.

Answer 7

7. 3. Numerous methods have been proposed to record the maternal perceptions of fetal
      movement or “kick counts.” A commonly used method is the Cardiff count-to-10 method. The client
      begins counting fetal movements at a specified time (eg, 8:00 AM ) and notes the time when the 10th
      movement is felt. If the client does not feel at least 6 movements in a 1-hour period, she should notify
      the health care provider. The fetus typically moves an average of 1 to 2 times every 10 minutes or 10
      to 12 times per hour. A 30- or 45-minute period is not enough time to evaluate fetal movement
      accurately. The client should monitor fetal movements more frequently than 1 time per week. One
      hour of monitoring each day is adequate.
      CN: Reduction of risk potential; CL: Evaluate

Question 8

8. When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs,
   which of the following types of diet should the nurse discuss?
9. High-residue diet.
10. Low-sodium diet.
11. Regular diet.
12. High-protein diet.

Answer 8

8. 3. For clients with mild preeclampsia, a regular diet with ample protein and calories is
      recommended. If the client experiences constipation, she should increase the fiber in her diet, such as
      by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional
      need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein
      diet is unnecessary.
      CN: Basic care and comfort; CL: Apply

Question 9

9. A 17-year-old client at 33 weeks’ gestation diagnosed with mild preeclampsia is treated as an
   outpatient. The nurse instructs the client to contact the health care provider immediately if she
   experiences which of the following?
10. Blurred vision.
11. Ankle edema.
12. Increased energy levels.
13. Mild backache.

Answer 9

9. 1. Severe headache, visual disturbances such as blurred vision, and epigastric pain are
      associated with the development of severe preeclampsia and possibly eclampsia. These danger signs
      and symptoms must be reported immediately. Severe headache and visual disturbances are related to
      severe vasoconstriction and a severe increase in blood pressure. Epigastric pain is related to hepatic
      dysfunction. Ankle edema is common during the third trimester. However, facial edema is associated
      with increased fluid retention and the progression from mild to severe preeclampsia. Increased
      energy levels are not associated with a progression of the client’s preeclampsia or the development of
      complications. In fact, some women report an “energy spurt” before the onset of labor. Mild backache
      is a common discomfort of pregnancy, unrelated to a progression of the client’s preeclampsia. It also
      may be associated with bed rest when the mattress is not firm. Some multiparous women have
      reported a mild backache as a sign of impending labor.
      CN: Reduction of risk potential; CL: Synthesize

Question 10

10. A primigravid client at 38 weeks’ gestation diagnosed with mild preeclampsia calls the clinic
    nurse to say she has a continuous headache for the past 2 days accompanied by nausea. The client
    does not want to take aspirin. The nurse should tell the client:
11. “Take two acetaminophen (Tylenol) tablets. They aren’t as likely to upset your stomach.”
12. “I think the doctor should see you today. Can you come to the clinic this morning?”
13. “You need to lie down and rest. Have you tried placing a cool compress over your head?”
14. “I’ll ask the doctor to call in a prescription for aspirin with codeine. What’s your pharmacy’s
    number?”

Answer 10

10. 2. A client with preeclampsia and a continuous headache for 2 days should be seen by a healthcare provider immediately. Continuous headache, drowsiness, and mental confusion indicate poor
       cerebral perfusion and are symptoms of severe preeclampsia. Immediate care is recommended
       because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to
       take two acetaminophen tablets would be inappropriate and may lead to further complications if the
       client is not evaluated and treated. Although the application of cool compresses may ease the pain
       temporarily, this would delay treatment. Aspirin with codeine may temporarily relieve the client’s
       headache. However, this delays immediate treatment, which is crucial. Additionally, pregnant women
       are advised not to take aspirin at this time because it may cause clotting problems in the neonate.
       Codeine generally is not prescribed.
       CN: Reduction of risk potential; CL: Synthesize

Question 11

11. When preparing the room for admission of a multigravid client at 36 weeks’ gestation
    diagnosed with severe preeclampsia, which of the following should the nurse obtain?
12. Oxytocin infusion solution.
13. Disposable tongue blades.
14. Portable ultrasound machine.
15. Padding for the side rails.V

Answer 11

11. 4. The client with severe preeclampsia may develop eclampsia, which is characterized by
       seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps
       decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also
       should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be
       obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be
       placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later
       point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is
       admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client
       and her fetus is the priority.
       CN: Physiological adaptation; CL: Apply

Question 12

12. The primary health care provider prescribes intravenous magnesium sulfate for a primigravid
    client at 38 weeks’ gestation diagnosed with severe preeclampsia. Which of the following
    medications should the nurse have readily available at the client’s bedside?
13. Diazepam (Valium).2. Hydralazine (Apresoline).
14. Calcium gluconate.
15. Phenytoin (Dilantin).

Answer 12

12. 3. The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The
       antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the
       client’s bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women.
       Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be
       used to treat seizures.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 13

13. For the client who is receiving intravenous magnesium sulfate for severe preeclampsia,
    which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
14. Decreased deep tendon reflexes.
15. Cool skin temperature.
16. Rapid pulse rate.
17. Tingling in the toes.

Answer 13

13. 1. Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a
       flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity
       increases. The nurse should check the client’s patellar, biceps, and radial reflexes regularly during
       magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the
       opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in
       hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.
       CN: Physiological adaptation; CL: Analyze

Question 14

14. A client at 28 weeks’ gestation presents to the emergency department with a “splitting
    headache. ” What actions are indicated by the nurse at this time? Select all that apply.
15. Reassure the client that headaches are a normal part of pregnancy.
16. Assess the client for vision changes or epigastric pain.
17. Obtain a nonstress test.
18. Assess the client’s reflexes and presence of clonus.
19. Determine if the client has a documented ultrasound for this pregnancy.

Answer 14

14. 2,3,4. Headaches could be a sign of preeclampsia/eclampsia in pregnancy. The client should
    be assessed for headache, vision changes, epigastric pain, hyper reflexes, and the presence of clonus.
    Her fetus should be assessed using a nonstress test. An ultrasound done in this pregnancy does not
    give information to assess the presence of preeclampsia/eclampsia.
    CN: Management of care; CL: Analyze

Question 15

15. Which of the following would the nurse identify as the priority to achieve when developing
    the plan of care for a primigravid client at 38 weeks’ gestation who is hospitalized with severe
    preeclampsia and receiving intravenous magnesium sulfate?
16. Decreased generalized edema within 8 hours.
17. Decreased urinary output during the first 24 hours.
18. Sedation and decreased reflex excitability within 48 hours.
19. Absence of any seizure activity during the first 48 hours.

Answer 15

15. 4. The highest priority for a client with severe preeclampsia is to prevent seizures, thereby
       minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe
       childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney
       damage, and maintain sedation are desirable but are not as important as preventing seizures. It wouldtake several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability
       can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much
       sooner than 48 hours.
       CN: Physiological adaptation; CL: Create

Question 16

16. The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34
    weeks’ gestation with severe preeclampsia. Which of the following are desired outcomes of this
    therapy? Select all that apply.
17. T 98 (36.7), P 72, R 14.
18. Urinary output less than 30 mL/h.
19. Fetal heart rate with late decelerations.
20. BP of less than 140/90.
21. DTR 2+.
22. Magnesium level = 5.6 mg/dL (2.8 mmol/L).

Answer 16

16. 1,5,6. The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous
    system by blocking peripheral neuromuscular transmissions and decreasing the amount of
    acetylcholine liberated. While being used, the temperature and pulse of the client should remain
    within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (RPM).
    Rates at 12 RPM or lower are associated with respiratory depression and are seen with magnesium
    toxicity. Renal compromise is identified with a urinary output of less than 30 mL/hour. A fetal heart
    rate that is maintained within the 112 to 160 range is desired without later or variable decelerations.
    Deep tendon reflexes should not be diminished or exaggerated. The therapeutic magnesium sulfate
    level of 5 to 8 mg/dL (2.5 to 4 mmol/L) is to be maintained.
    CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 17

17. Soon after admission of a primigravid client at 38 weeks’ gestation with severe
    preeclampsia, the primary health care provider prescribes a continuous intravenous infusion of 5%
    dextrose in Ringer’s solution and 4 g of magnesium sulfate. While the medication is being
    administered, which of the following assessment findings should the nurse report immediately?
18. Respiratory rate of 12 breaths/min.
19. Patellar reflex of +2.
20. Blood pressure of 160/88 mm Hg.
21. Urinary output exceeding intake.

Answer 17

17. 1. A respiratory rate of 12 breaths/min suggests potential respiratory depression, an adverse
       effect of magnesium sulfate therapy. The medication must be stopped and the primary health care
       provider should be notified immediately. A patellar reflex of +2 is normal. Absence of a patellar
       reflex suggests magnesium toxicity. A blood pressure reading of 160/88 mm Hg would be a common
       finding in a client with severe preeclampsia. Urinary output exceeding intake is not likely in a client
       receiving intravenous magnesium sulfate. Oliguria is more common.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 18

18. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe
    preeclampsia, the client begins to experience a seizure. Which of the following should the nurse dofirst?
19. Insert an airway to improve oxygenation.
20. Note the time when the seizure begins and ends.
21. Call for immediate assistance.
22. Turn the client to her left side.

Answer 18

18. 3. If a client begins to have a seizure, the first action by the nurse is to remain with the client
       and call for immediate assistance. The nurse needs to have some assistance in managing this client.
       After the seizure, the client needs intensive monitoring. An airway can be inserted, if appropriate,
       after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side
       should be done after assistance is obtained.
       CN: Reduction of risk potential; CL: Synthesize

Question 19

19. After administering hydralazine (Apresoline) 5 mg intravenously as prescribed for a
    primigravid client with severe preeclampsia at 39 weeks’ gestation, the nurse should assess the client
    for:
20. Tachycardia.
21. Bradypnea.
22. Polyuria.
23. Dysphagia.

Answer 19

19. 1. One of the most common adverse effects of the drug hydralazine (Apresoline) is
       tachycardia. Therefore, the nurse should assess the client’s heart rate and pulse. Hydralazine acts to
       lower blood pressure by peripheral dilation without interfering with placental circulation. Bradypnea
       and polyuria are usually not associated with hydralazine use. Dysphagia is not a typical adverse
       effect of hydralazine.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 20

20. A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar
    reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of
    the following?
21. 1+.
22. 2+.
23. 3+.
24. 4+.

Answer 20

20. 4. These findings would be documented as 4+. 1+ indicates a diminished response; 2+
       indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal.
       Mild clonus is said to be present when there are two movements.
       CN: Physiological adaptation; CL: Apply

Question 21

21. A 16-year-old unmarried primigravid client at 37 weeks’ gestation with severe preeclampsia
    is in early active labor. The client’s blood pressure is 164/110 mm Hg. Which of the following would
    alert the nurse that the client may be about to experience a seizure?
22. Decreased contraction intensity.
23. Decreased temperature.
24. Epigastric pain.
25. Hyporeflexia.

Answer 21

21. 3. Epigastric pain or acute right upper quadrant pain is associated with the development of
       eclampsia and an impending seizure; this is thought to be related to liver ischemia. Decreased
       contraction intensity is unrelated to the severity of the preeclampsia. Typically, the client’s
       temperature increases because of increased cerebral pressure. A decrease in temperature is unrelatedto an impending seizure. Hyporeflexia is not associated with an impending seizure. Typically, the
       client would exhibit hyperreflexia.
       CN: Physiological adaptation; CL: Analyze

Question 22

22. Following an eclamptic seizure, the nurse should assess the client for which of the following?
23. Polyuria.
24. Facial flushing.
25. Hypotension.
26. Uterine contractions.

Answer 22

22. 4. After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse
       must continually monitor the client for signs of impending labor, because the client will not be able to
       verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic
       seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the
       client remains hypertensive unless medications such as magnesium sulfate are administered.
       CN: Physiological adaptation; CL: Analyze

Question 23

23. A client at 36 weeks' gestation begins to exhibit signs of labor after an eclamptic seizure. The
nurse should assess the client for:
1. Abruptio placentae.
2. Transverse lie.
3. Placenta accreta.
4. Uterine atony.

Answer 23

23. 1. After an eclamptic seizure, the client is at risk for abruptio placentae due to severe
       vasoconstriction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested
       by a board-like abdomen and an abnormal fetal heart rate tracing. Transverse lie or shoulder
       presentation, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse
       lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus,
       placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fluid. Placenta accreta, a
       rare phenomenon, refers to a condition in which the placenta abnormally adheres to the uterine lining.
       Uterine atony, or relaxed uterus, may occur after childbirth, leading to postpartum hemorrhage.
       CN: Physiological adaptation; CL: Analyze

Question 24

24. The nurse is reviewing the chart of a multigravid client at 39 weeks’ gestation with suspected
    HELLP syndrome. The nurse should notify the health care provider about which of the following test
    results?
25. Platelets 200,000 mm 3 (200 × 10 9 /L).
26. Lactate dehydrogenase (LDH) greater than 200 U/L (3.34 μkat/L).3. Uric acid 3 mg/dL (178.4 μmol/L).
27. Aspartate aminotransferase (AST) 15 U/L (0.25 μkat/L)

Answer 24

24. 2. The normal value of LDH in a nonpregnant person is 45 to 90 U/L (0.75 to 1.5 μkat/L).
       LDH elevations indicate tissue destruction that can occur with HELLP syndrome. This platelet range
       is in the normal range and remains unchanged during pregnancy. Uric acid in a nonpregnant woman is
       2 to 6.6 mg/dL (119 to 393 μmol/L). AST normal range is 4 to 20 U/L (0.07 to 0.33 μkat/L).
       CN: Reduction of risk potential; CL: Synthesize

Question 25

The Pregnant Client with a Chronic Hypertensive
Disorder

25. An obese 36-year-old multigravid client at 12 weeks’ gestation has a history of chronic
    hypertension. She was treated with methyldopa before becoming pregnant. When counseling the client
    about diet during pregnancy, the nurse realizes that the client needs additional instruction when she
    states which of the following?
26. “I need to reduce my caloric intake to 1,200 cal/day.”
27. “A regular diet is recommended during pregnancy.”
28. “I should eat more frequent meals if I get heartburn.”
29. “I need to consume more fluids and fiber each day.”

Answer 25

The Pregnant Client with a Chronic Hypertensive Disorder
25. 1. Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need
to consume adequate calories to support fetal growth and development. They also need an adequate
protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating
more frequent, smaller meals decreases heartburn resulting from the reflux of acidic secretions into
the lower esophagus. Pregnant women need adequate hydration (fluids) and fiber to prevent
constipation.
CN: Basic care and comfort; CL: Evaluate

Question 26

26. After instructing a multigravid client at 10 weeks’ gestation diagnosed with chronic
    hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have
    been successful when the client states which of the following?
27. “I may develop hyperthyroidism because of my high blood pressure.”
28. “I need close monitoring because I may have a small-for-gestational-age infant.”
29. “It’s possible that I will have excess amniotic fluid and may need a cesarean section.”
30. “I may develop placenta accreta, so I need to keep my clinic appointments.”

Answer 26

26. 2. Women with chronic hypertension during pregnancy are at risk for complications such as
       preeclampsia (about 25%), abruptio placentae, and intrauterine growth retardation, resulting in a
       small-for-gestational-age infant. There is no association between chronic hypertension and
       hyperthyroidism. Pregnant women with chronic hypertension are not at an increased risk for
       hydramnios (polyhydramnios), an abnormally large amount of amniotic fluid. Clients with diabetes
       and multiple gestations are at risk for this condition. Placenta accreta, a rare placental abnormality,
       refers to a condition in which the placenta abnormally adheres to the uterine lining. It is not
       associated with chronic hypertension.
       CN: Reduction of risk potential; CL: Evaluate

Question 27

27. After reinforcing the danger signs to report with a gravida 2 client at 32 weeks’ gestation with
    an elevated blood pressure, which client statements would demonstrate her understanding of when to
    call the primary health care provider’s office? Select all that apply.
28. “If I get up in the morning and feel dizzy, even if the dizziness goes away.”
29. “If I see any bleeding, even if I have no pain.”
30. “If I have a pounding headache that doesn’t go away.”
31. “If I notice the veins in my legs getting bigger.”
32. “If the leg cramps at night are waking me up.”
33. “If the baby seems to be more active than usual.”

Answer 27

27. 2,3,6. Vaginal bleeding with or without pain could signify placenta previa or abruptio
    placentae. Continuous or pounding headache could indicate an elevated blood pressure, and change in
    the strength or frequency of fetal movements could indicate that the fetus is in distress. Orthostatic
    hypotension can occur during pregnancy and can be alleviated by rising slowly. Leg veins may
    increase in size due to additional pressure from the increasing uterine size, while leg cramps may
    also occur and can commonly be decreased with calcium supplements.
    CN: Reduction of risk potential; CL: Evaluate

Question 28

The Pregnant Bleeding Client with Third-Trimester

28. A client presents to the OB triage unit with no prenatal care and painless bright red vaginal
    bleeding. Which interventions are most indicated?
29. Applying external fetal monitor and complete physical assessment.
30. Applying external fetal monitor and perform sterile vaginal exam.
31. Obtaining a fundal height physical assessment on the patient.
32. Obtaining fundal height and a sterile vaginal exam.

Answer 28

The Pregnant Client with Third-Trimester Bleeding
28. 1. Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile
vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying
the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment
of the patient is indicated. A fundal height is used to monitor fetal growth during pregnancy but does
not provide information related to vaginal bleeding.
CN: Reduction of risk potential; CL: Analyze

Question 29

29. A client presents to the OB triage unit with a report of bright red vaginal bleeding that has
    saturated a peripad over the last hour. The nurse observes the fetal heart rate with a baseline of 130
    decreasing to 100 for 60 seconds and then returning to 130. There are no contractions present. Which
    are the priority nursing interventions?
30. Ask client time of last oral intake and prepare to start an IV.
31. Continue to observe monitor and perform Leopold’s maneuver.
32. Apply oxygen by face mask and perform sterile vaginal exam.
33. Place client in hands and knees position and call primary health care provider.

Answer 29

29. 1. Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile
       vaginal exam should never be done on a woman with a known or suspected placenta previa. Because
       the woman is currently bleeding and the fetal heart rate is showing decelerations, the woman would
       need fluid replacement and a possible emergent cesarean birth. The woman may also need fluid
       volume replacement. The nurse can prepare for this by asking last oral intake obtaining IV access.
       The client should be placed in a lateral position to enhance uteroplacental blood flow and given
       oxygen. The nurse should notify the primary health care provider as soon as possible, but the hands
       and knees position is indicated only if the client is experiencing back labor or umbilical cord
       prolapse. Leopold’s maneuver is done to determine fetal position in utero and would have already
       been done prior to placing the fetal heart rate monitor.
       CN: Reduction of risk potential; CL: Analyze

Question 30

30. The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular
    coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health
    care provider?
31. Activated partial thromboplastin time (APTT) of 30 seconds.
32. Hemoglobin of 11.5 g/dL (115 g/L).
33. Urinary output of 25 mL in the past hour.
34. Platelets at 149,000/mm 3 (149 × 10 9 /L).

Answer 30

30. 3. Urinary output of less than 30 mL/h indicates renal compromise and would be the most
       important assessment finding to report to the health care provider. The APTT is within normal limits
       and the hemoglobin is lower than values for an adult female but within normal limits for a pregnant
       female. Although the platelet level is slightly low and may impact blood clotting, when compared to
       renal failure, it is less important.
       CN: Management of care; CL: Synthesize

Question 31

31. A 24-year-old client, G 3, P 1, at 32 weeks’ gestation, is admitted to the hospital because of
    vaginal bleeding. After reviewing the client’s history, which of the following factors might lead the
    nurse to suspect abruptio placentae?
32. Several hypotensive episodes.
33. Previous low transverse cesarean birth.
34. One induced abortion.
35. History of cocaine use.

Answer 31

31. 4. Although the exact cause of abruptio placentae is unknown, possible contributing factors
       include excessive intrauterine pressure caused by hydramnios or multiple pregnancy, cocaine use,
       cigarette smoking, alcohol ingestion, trauma, increased maternal age and parity, and amniotomy. A
       history of hypertension is associated with an increased risk of abruptio placentae. A previous low
       transverse cesarean section and a history of one induced abortion are associated with increased risk
       of placenta previa, not abruptio placentae.
       CN: Physiological adaptation; CL: Analyze

Question 32

32. When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38
    weeks’ gestation, which of the following would the nurse anticipate administering intravenously if the
    client develops disseminated intravascular coagulation (DIC)?
33. Ringer’s lactate solution.
34. Fresh frozen platelets.
35. 5% dextrose solution.
36. Warfarin sodium (Coumadin).

Answer 32

32. 2. Treatment of DIC includes treating the causative factor, replacing maternal coagulation
       factors, and supporting physiologic functions. Intravenous infusions of whole blood, fresh-frozen
       plasma, or platelets are used to replace depleted maternal coagulation factors. Although Ringer’slactate solution and 5% dextrose solution may be used as intravenous fluid replacement, the client
       needs blood component therapy. Therefore, normal saline must be used. Intravenous heparin, not
       warfarin sodium (Coumadin) may be administered to halt the clotting cascade.
       CN: Physiological adaptation; CL: Analyze

Question 33

33. When assessing a 34-year-old multigravid client at 34 weeks’ gestation experiencing
    moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta
    previa is present?1. Painless vaginal bleeding.
34. Uterine tetany.
35. Intermittent pain with spotting.
36. Dull lower back pain.

Answer 33

33. 1. The most common assessment finding associated with placenta previa is painless vaginal
       bleeding. With placenta previa, the placenta is abnormally implanted, covering a portion or all of the
       cervical os. Uterine tetany, intermittent pain with spotting, and dull lower back pain are not
       associated with placenta previa. Uterine tetany is associated with oxytocin administration.
       Intermittent pain with spotting commonly is associated with a spontaneous abortion. Dull lower back
       pain is commonly associated with poor maternal posture or a urinary tract infection with renal
       involvement.
       CN: Physiological adaptation; CL: Analyze

Question 34

34. The primary health care provider prescribes whole blood replacement for a multigravid
    client with abruptio placentae. Before administering the intravenous blood product, the nurse should
    first:
35. Validate client information and the blood product with another nurse.
36. Check the vital signs before transfusing over 5 to 6 hours.
37. Ask the client if she has ever had any allergies.
38. Administer 100 mL of 5% dextrose solution intravenously.

Answer 34

34. 1. When administering blood replacement therapy, extreme caution is needed. Before
       administering any blood product, the nurse should validate the client information and the blood
       product with another nurse to prevent administration of the wrong blood transfusion. Although
       baseline vital signs are necessary, she should initiate the infusion of blood slowly for the first 10 to
       15 minutes. Then, if there is no evidence of a reaction, she should adjust the rate of infusion to ensure
       that the blood product is infused over 2 to 4 hours. The nurse can ask the client if she has ever had a
       reaction to a blood product, but a general question about allergies may not elicit the most complete
       response about any reactions to blood product administration. Blood transfusions are typically given
       with intravenous normal saline solution, not dextrose solutions.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 35

35. Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, “I feel
    like such a failure. None of my other childbirths were like this.” The nurse’s response to the client is
    based on the understanding of which of the following?
36. The client will most likely have postpartum blues.
37. Maternal-infant bonding is likely to be difficult.
38. The client’s feeling of grief is a normal reaction.
39. This type of birth was necessary to save the client’s life.

Answer 35

35. 3. Feelings of loss, grief, and guilt are normal after a cesarean birth, particularly if it was not
       planned. The nurse should support the client, listen with empathy, and allow the client time to grieve.
       The likelihood of the client experiencing postpartum blues is not known, and no evidence is
       presented. Although maternal-infant bonding may be delayed owing to neonatal complications or
       maternal pain and subsequent medications, it should not be difficult. Although the nurse is aware that
       this type of birth was necessary to save the client’s life, using this as the basis for the response does
       not acknowledge the mother’s feelings.
       CN: Psychosocial integrity; CL: Apply

Question 36

36. A client has received epidural anesthesia to control pain during a vaginal birth. Place an X
    over the highest point on the body locating the level of anesthesia expected for a vaginal birth.

Answer 36

36.The level of anesthesia achieved via epidural anesthesia for a vaginal birth is T10
(approximately the level of the umbilicus). Epidural anesthesia for a cesarean birth would be at the
level of T4 to T6, approximately the nipple line.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 37

37. The nurse should do which of the following actions first when admitting a multigravid client
    at 36 weeks’ gestation with a probable diagnosis of abruptio placentae?
38. Prepare the client for a vaginal examination.
39. Obtain a brief history from the client.
40. Insert a large-gauge intravenous catheter.
41. Prepare the client for an ultrasound scan.

Answer 37

37. 3. Abruptio placentae is a medical emergency because the degree of hypovolemic shock maybe out of proportion to visible blood loss. On admission, the nurse should plan to first insert a large-
       gauge intravenous catheter for fluid replacement and oxygen by mask to decrease fetal anoxia. Vaginal
       examination usually is not performed on pregnant clients who are experiencing third-trimester
       bleeding due to abruptio placentae because it can result in damage to the placenta and further fetal
       anoxia. The client’s history can be obtained once the client has been admitted and the intravenous line
       has been started. The goal is birth of the fetus, usually by emergency cesarean section. The nurse
       should also plan to monitor the client’s vital signs and the fetal heart rate. Ultrasound is of limited use
       in the diagnosis of abruptio placentae.
       CN: Reduction of risk potential; CL: Synthesize

Question 38

The Pregnant Client with Preterm Labor

38. The health care provider has determined that a preterm labor client at 34 weeks’ gestation has
    no fetal fibronectin present. Based on this finding, the nurse would anticipate that within the next
    week:
39. The client will develop preeclampsia.
40. The fetus will develop mature lungs.
41. The client will not develop preterm labor.
42. The fetus will not develop gestational diabetes.

Answer 38

38. 3. The absence of fetal fibronectin in a vaginal swab between 22 and 37 weeks’ gestation
       indicates there is less than 1% risk of developing preterm labor in the next week. Fetal fibronectin is
       an extra cellular protein normally found in fetal membranes and deciduas and has no correlation with
       preeclampsia, fetal lung maturation, or gestational diabetes.
       CN: Reduction of risk potential; CL: Synthesize

Question 39

39. A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner
    ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further
    instruction when they state which of the following?
40. “I need to stay hydrated all the time.”
41. “I need to avoid any infections.”
42. “I should include frequent rest breaks if we travel.”
43. “Changing to filter cigarettes is helpful.”

Answer 39

39. 4. Smoking in any form is contraindicated in pregnancy, regardless of the type of filtering
       system used. Smoking is a major risk factor for preterm labor and decreased fetal weight.
       Dehydration is a risk factor for preterm labor as is prolonged standing and remaining in one position.
       Infection is thought to be a primary cause of preterm labor and the client would need to avoid
       contracting any type of infection. While taking trips, frequent emptying of the bladder prevents
       infection and ambulates the woman.
       CN: Management of care; CL: Evaluate

Question 40

40. A multigravid client at 34 weeks’ gestation is being treated with indomethacin (Indocin) to
    halt preterm labor. If the client gives birth to a preterm infant, the nurse should notify the nursery
    personnel about this therapy because of the possibility for which of the following?
41. Pulmonary hypertension.
42. Respiratory distress syndrome (RDS).
43. Hyperbilirubinemia.
44. Cardiomyopathy.

Answer 40

40. 1. Indomethacin (Indocin) has been successfully used to halt preterm labor. However, if the
       client should give birth to a preterm infant, the nurse would notify the nursery personnel about the
       tocolytic therapy because this drug can lead to premature closure of the fetal ductus arteriosus,
       resulting in pulmonary hypertension. Prematurity is associated with RDS because of the immaturity of
       the fetal lungs. RDS is not a result of indomethacin. Hyperbilirubinemia is more common in preterm
       infants. Use of indomethacin to halt preterm labor is not associated with cardiomyopathy in the infant.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 41

41. Which statement by the client indicates an understanding of the teaching regarding the use of
    magnesium sulfate and corticosteroids for preterm labor?
42. “I will be on magnesium sulfate and corticosteroids until my baby’s due date, so he has the best
    chance of doing well.”
43. “The magnesium sulfate is to stop contractions while the corticosteroids increase lung
    surfactant in my baby so he can breathe better if he is born early.”
44. “The goal of the magnesium sulfate and the corticosteroids is to stop contractions and help me
    get to my due date.”
45. “If I take this magnesium sulfate and the corticosteroids, my baby won’t have to spend any time
    in the neonatal intensive care unit if he is born.”

Answer 41

41. 2. Corticosteroids given IM have been shown to increase fetal lung surfactant and reduce the
       risk of respiratory distress syndrome in premature infants. It is not a guarantee that a premature
       newborn would not have problems at birth that would require time in the neonatal intensive care unit.
       The administration of the corticosteroids is normally completed within 24 to 48 hours. Magnesium
       sulfate is currently given IV to women in preterm labor to stop contractions and therefore prolong
       gestation long enough for the corticosteroids to be most effective for the fetus. Magnesium sulfate is
       not always effective at stopping preterm labor.
       CN: Pharmacology and IVs; CL: Evaluate

Question 42

42. In which of the following maternal locations would the nurse place the ultrasound transducer
    of the external electronic fetal heart rate monitor if a fetus at 34 weeks’ gestation is in the left
    occipitoanterior (LOA) position?
43. Near the symphysis pubis.
44. Two inches (5.1 cm) above the umbilicus.
45. Below the umbilicus on the left side.
46. At the level of the umbilicus.

Answer 42

42. 3. As the uterus contracts, the abdominal wall rises and, when external monitoring is used,
       presses against the transducer. This movement is transmitted into an electrical current, which is then
       recorded. With the fetus in the LOA position, the cardiotransducer should be placed below the
       umbilicus on the side where the fetal back is located and uterine displacement during contractions isgreatest. If the fetal back is near the symphysis pubis, the fetus is presenting as a transverse lie. If the
       fetus is in a breech position, the fetal back may be at or above the umbilicus.
       CN: Reduction of risk potential; CL: Apply

Question 43

43. The primary health care provider prescribes betamethasone for a 34-year-old multigravid
    client at 32 weeks’ gestation who is experiencing preterm labor. Previously, the client hasexperienced one infant death due to preterm birth at 28 weeks’ gestation. The nurse explains that this
    drug is given for which of the following reasons?
44. To enhance fetal lung maturity.
45. To counter the effects of tocolytic therapy.
46. To treat chorioamnionitis.
47. To decrease neonatal production of surfactant.

Answer 43

43. 1. Betamethasone therapy is indicated when the fetal lungs are immature. The fetus must be
       between 28 and 34 weeks’ gestation and birth must be delayed for 24 to 48 hours for the drug to
       achieve a therapeutic effect. Antibiotics would be used to treat chorioamnionitis. Betamethasone is
       not an antagonist for tocolytic therapy. It increases, not decreases, the production of neonatal
       surfactant.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 44

44. A client at 28 weeks’ gestation in premature labor was placed on nifedipine (Procardia). To
    maintain the pregnancy, the primary health care provider prescribes the client to have 20 mg now,
    followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral
    dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the
    medication at 0600?
    ___________________________________ AM / PM

Answer 44

44. 2200. If 20 mg were administered at 0600 and then 20 mg were administered at 1400, the
          dose at 2200 reached the maximum oral dose of 60 mg/day.
          CN: Pharmacological and parenteral therapies; CL: Apply

Question 45

45. When preparing a multigravid client at 34 weeks’ gestation experiencing preterm labor for the
    shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to
    evaluate the maturity of which of the following fetal systems?
46. Urinary.
47. Gastrointestinal.
48. Cardiovascular.
49. Pulmonary.

Answer 45

45. 4. The shake test helps determine the maturity of the fetal pulmonary system. The test is based
       on the fact that surfactant foams when mixed with ethanol. The more stable the foam, the more mature
       the fetal pulmonary system. Although the shake test is inexpensive and provides rapid results,
       problems have been noted with its reliability. Therefore, the lecithin-sphingomyelin ratio is usually
       determined in conjunction with the shake test.
       CN: Reduction of risk potential; CL: Apply

Question 46

The Pregnant Client with Premature Rupture of the Membranes

46. The nurse is planning care for a multigravid client hospitalized at 36 weeks’ gestation with
    confirmed rupture of membranes and no evidence of labor. Which of the following would the nurse
    expect the primary health care provider to prescribe?
47. Frequent assessments of cervical dilation.
48. Intravenous oxytocin administration.
49. Vaginal culture for Neisseria gonorrhoeae.
50. Sonogram for amniotic fluid volume index

Answer 46

The Pregnant Client with Premature Rupture of the Membranes
46. 3. Because an intrauterine infection may occur when membranes have ruptured, vaginal
cultures for N. gonorrhoeae, group B streptococcus, and chlamydia are usually taken. Prophylactic
antibiotics may be prescribed to reduce the risk of infection in the newborn. Frequent vaginal
examinations should be avoided because they can further increase the client’s risk for infection.
Intravenous oxytocin to initiate labor may be used if an infection occurs. Bed rest can sometimes
prolong the pregnancy and prevent a preterm birth. A sonogram may be used to validate rupture of the
membranes with an amniotic fluid index. However, it is not needed if the primary health care
provider has confirmed the rupture.
CN: Reduction of risk potential; CL: Apply

Question 47

47. A multigravid client at 34 weeks’ gestation visits the hospital because she suspects that her
    water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the
    client’s membranes have ruptured when the paper turns which of the following colors?
48. Yellow.
49. Green.
50. Blue.
51. Red.

Answer 47

47. 3. If the client’s membranes have ruptured, the nitrazine paper will turn blue, an alkaline
       reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The
       definitive test for rupture of membranes is fern testing, where amniotic fluid is allowed to dry on a
       slide and then viewed under a microscope. Dried amniotic fluid will form a fern pattern. No other
       fluid forms this type of pattern.
       CN: Reduction of risk potential; CL: Analyze

Question 48

48. A primigravid client at 30 weeks’ gestation has been admitted to the hospital with premature
    rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The
    nurse should next assess the client’s:
49. Red blood cell count.
50. Degree of discomfort.
51. Urinary output.
52. Temperature.

Answer 48

48. 4. Premature rupture of the membranes is commonly associated with chorioamnionitis, or an
       infection. A priority assessment for the nurse to make is to document the client’s temperature every 2
       to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood
       cell count also indicate an infection. The red blood cell count would provide information related to
       anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a
       priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.CN: Reduction of risk potential; CL: Analyze

Question 49

49. A multigravid client at 34 weeks’ gestation with premature rupture of the membranes tests
    positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital
    signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm;
    respirations, 18 breaths/min. Which of the following would the nurse expect the primary health care
    provider to prescribe?
50. Intravenous penicillin.
51. Intravenous gentamicin sulfate.
52. Intramuscular betamethasone.
53. Intramuscular cefaclor.

Answer 49

49. 1. Because group B streptococcus is a gram-positive bacterium, the primary health care
       provider probably will prescribe intravenous penicillin to treat the mother’s infection and prevent
       fetal infection. Gentamicin sulfate, which acts on gram-negative bacteria, would be inappropriate.
       Administering a corticosteroid, such as betamethasone, is inappropriate because the premature
       rupture of the membranes enhances fetal lung maturity. The lack of amniotic fluid causes early
       maturation of lung tissue. Cefaclor, which is available only in the oral form, is used for upper and
       lower respiratory tract infections and urinary tract infections by gram-negative staphylococci.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 50

50. A primigravid client at 36 weeks’ gestation with premature rupture of the membranes is to be
    discharged home on bed rest with follow-up by the home health nurse. After instruction about care
    while at home, which of the following client statements indicates effective teaching?
51. “It is permissible to douche if the fluid irritates my vaginal area.”
52. “I can take either a tub bath or a shower when I feel like it.”
53. “I should limit my fluid intake to less than 1 quart (0.95 L) daily.”
54. “I should contact the doctor if my temperature is 100.4°F (38°C) or higher.”

Answer 50

50. 4. Because of the client’s increased risk for infection, successful teaching is indicated when
       the client states that she will contact the doctor if her temperature is 100.4°F (38°C) or greater. The
       client should be instructed to monitor her temperature twice daily. The client should refrain from
       coitus, douching, and tub bathing, which can increase the potential for infection. Showering is
       permitted because water in the shower doesn’t enter the vagina and increase the risk of infection. A
       fluid intake of at least 2 L daily is recommended to prevent potential urinary tract infection.
       CN: Reduction of risk potential; CL: Evaluate

Question 51

51. A primigravid client at 34 weeks’ gestation is experiencing contractions every 3 to 4 minuteslasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the
    client’s vital signs, the client says, “I think my bag of water just broke.” Which of the following would
    the nurse do first?
52. Check the status of the fetal heart rate.
53. Turn the client to her right side.
54. Test the leaking fluid with nitrazine paper.
55. Perform a sterile vaginal examination.

Answer 51

51. 1. The priority is to determine whether a prolapsed cord has occurred as a result of the
       spontaneous rupture of membranes. The nurse’s first action should be to check the status of the fetal
       heart rate. Complications of premature rupture of the membranes include a prolapsed cord or
       increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decelerations
       or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning
       the client to her right side is not necessary. If the cord does prolapse, the client should be placed in a
       knee-to-chest or Trendelenburg position. Checking the fluid with nitrazine paper and vaginal
       examination are appropriate once the status of the fetus has been evaluated.
       CN: Reduction of risk potential; CL: Synthesize

Question 52

The Pregnant Client with Diabetes Mellitus
52. A client with gestational diabetes who is entering her third trimester is learning how to
monitor her fetus’s movements. After teaching the client about the kick count, the nurse should provide
further instruction if the client makes which of the following statements?
1. “The baby may be more active at different times of the day.”
2. “How I feel my baby move is different than my friend.”
3. “The baby should be moving less than 10 times in 2 hours.”
4. “The baby may not move at times because it is asleep.”

Answer 52

The Pregnant Client with Diabetes Mellitus
52. 3. Feeling four kicks in 30 minutes or feeling 10 or more kicks in 2 hours are norms. Fetuses
are more active at various times of the day particularly after a mother has eaten (when the blood
glucose level is high) and in the evening. Each individual perceives their fetus to move differently.
Fetuses do sleep several times per day for about 30 minutes each time.
CN: Safety and infection control; CL: Evaluate

Question 53

53. A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks’ gestation
    undergoes a nonstress test, the results of which are documented as reactive. The nurse should tell the
    client that the test results indicate which of the following?
54. A contraction stress test is necessary.
55. The nonstress test should be repeated.
56. Chorionic villus sampling is necessary.
57. There is evidence of fetal well-being.

Answer 53

53. 4. The nonstress test is considered reactive when two or more fetal heart rate accelerations of
       at least 15 bpm occur (from a baseline fetal heart rate of 120 to 160 bpm), along with fetal movement,
       during a 10- to 20-minute period. A reactive nonstress test indicates fetal heart rate accelerations and
       well-being. There is no indication for further evaluation (such as a contraction stress test). However,
       contraction stress tests are commonly scheduled for pregnant clients with insulin-dependent diabetes
       in the latter part of pregnancy and are repeated periodically until birth. Chorionic villus sampling is
       usually performed early in the pregnancy to detect fetal abnormalities.
       CN: Reduction of risk potential; CL: Synthesize

Question 54

54. A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress
    test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that
    the fetal heart rate pattern showed which of the following?
55. Frequent late decelerations.
56. Decreased fetal movement.
57. Inconsistent late decelerations.
58. Lack of fetal movement.

Answer 54

54. 3. A contraction stress test is used to evaluate fetal well-being during a simulated labor. Asuspicious contraction stress test indicates inconsistent late deceleration patterns requiring further
       evaluation. A negative contraction stress test indicates no late decelerations and is the desired
       outcome. A positive contraction stress test indicates fetal compromise with frequent late
       decelerations. Fetal movements are one of the parameters of a biophysical profile and are detected
       with nonstress testing. Decreased or absent fetal movements may indicate central nervous system
       dysfunction or prematurity. Lack of fetal movement or decreased fetal movement is not associated
       with contraction stress testing.
       CN: Reduction of risk potential; CL: Analyze

Question 55

55. Which of the following statements about a fetal biophysical profile would be incorporated
    into the teaching plan for a primigravid client with insulin-dependent diabetes?
56. It determines fetal lung maturity.
57. It is noninvasive using real-time ultrasound.
58. It will correlate with the newborn’s Apgar score.
59. It requires the client to have an empty bladder.

Answer 55

55. 2. The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five
       parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal
       tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other
       four parameters are determined by ultrasound scanning. The results are available as soon as the test is
       completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity.
       Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for
       compromise, there is no correlation with the newborn’s Apgar score. The biophysical score is
       sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of
       an ultrasound requires the mother to have a full bladder.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 56

56. A 30-year-old multigravid client at 8 weeks’ gestation has a history of insulin-dependent
    diabetes since age 20. When explaining about the importance of blood glucose control during
    pregnancy, the nurse should tell the client that which of the following will occur regarding the client’s
    insulin needs during the first trimester?
57. They will increase.
58. They will decrease.
59. They will remain constant.
60. They will be unpredictable.

Answer 56

56. 2. During the first trimester, it is not unusual for insulin needs to decrease, commonly as a
       result of nausea and vomiting. Progressive insulin resistance is characteristic of pregnancy,
       particularly in the second half of pregnancy. It is not unusual for insulin needs to increase by as much
       as four times the nonpregnant dose after about the 24th week of gestation. This resistance is caused by
       the production of human placental lactogen, also called human chorionic somatotropin, by the
       placenta and by other hormones, such as estrogen and progesterone, which are insulin antagonists.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 57

57. The nurse explains the complications of pregnancy that occur with diabetes to a primigravid
    client at 10 weeks’ gestation who has a 5-year history of insulin-dependent diabetes. Which of the
    following, if stated by the client as a complication, indicates the need for additional teaching?
58. Candida albicans infection.
59. Twin-to-twin transfer.3. Polyhydramnios.
60. Preeclampsia.

Answer 57

57. 2. Clients who are pregnant and have diabetes are not at greater risk for multifetal pregnancy
       and subsequent twin-to-twin transfer unless they have undergone fertility treatments. The pregnant
       diabetic client is at higher risk for complications such as infection, polyhydramnios, ketoacidosis, and
       preeclampsia, compared with the pregnant nondiabetic client.
       CN: Reduction of risk potential; CL: Evaluate

Question 58

58. When developing a teaching plan for a primigravid client with insulin-dependent diabetes
    about monitoring blood glucose control and insulin dosages at home, which of the following would
    the nurse expect to include as a desired target range for blood glucose levels?
59. 40 to 60 mg/dL (2.2 to 3.3 mmol/L) between 2:00 and 4:00 PM
60. 70 to 100 mg/dL (3.3 to 5.6 mmol/L) before meals and bedtime snacks.
61. 110 to 140 mg/dL (6.2 to 7.8 mmol/L) before meals and bedtime snacks.
62. 140 to 160 mg/dL (7.8 to 8.9 mmol/L) 1 hour after meals.

Answer 58

58. 2. The goal is to maintain blood plasma glucose levels at 70 to 100 mg/dL (3.5 to 5.6 mmol/L)
       before meals and bedtime snacks. Below 60 mg/dL (5.6 mmol/L) indicates hypoglycemia. A range of
       110 to 140 mg/dL (6.2 to 7.8 mmol/L) suggests hyperglycemia. The target range 1 hour after meals is
       100 to 120 mg/dL (5.6 to 6.7 mmol/L).
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 59

59. When teaching a primigravid client with diabetes about common causes of hyperglycemia
    during pregnancy, which of the following would the nurse include?
60. Fetal macrosomia.
61. Obesity before conception.
62. Maternal infection.
63. Pregnancy-induced hypertension.

Answer 59

59. 3. Maternal infection is the most common cause of maternal hyperglycemia and can lead to
       ketoacidosis, coma, and death. The client should notify the primary health care provider immediately
       if she experiences symptoms of an infection. Fetal macrosomia, obesity before conception, and
       pregnancy-induced hypertension are not associated with maternal hyperglycemia during pregnancy.
       CN: Physiological adaptation; CL: Create

Question 60

60. After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia,
    the nurse determines that the client understands the instruction when she says that hyperglycemia may
    be manifested by which of the following?
61. Dehydration.
62. Pallor.
63. Sweating.
64. Nervousness.

Answer 60

60. 1. Dehydration, polyuria, fatigue, flushed hot skin, dry mouth, and drowsiness aremanifestations of hyperglycemia. Hyperglycemia is a medical emergency and requires immediate
       action to prevent maternal and fetal mortality. Pallor, sweating, and nervousness are early signs of
       hypoglycemia, not hyperglycemia.
       CN: Reduction of risk potential; CL: Evaluate

Question 61

61. At 38 weeks’ gestation, a primigravid client with poorly controlled diabetes and severe
    preeclampsia is admitted for a cesarean birth. The nurse explains to the client that childbirth helps to
    prevent which of the following?
62. Neonatal hyperbilirubinemia.
63. Congenital anomalies.
64. Perinatal asphyxia.
65. Stillbirth.

Answer 61

61. 4. Stillbirths caused by placental insufficiency occur with increased frequency in women with
       diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience
       unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly
       induced in these clients before term. If induction of labor fails, a cesarean section is necessary.
       Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or
       perinatal asphyxia.
       CN: Reduction of risk potential; CL: Apply

Question 62

62. A primigravid client with diabetes at 39 weeks’ gestation is seen in the high-risk clinic. The
    primary health care provider estimates that the fetus weighs at least 4,500 g (10 lb). The client asks,
    “What causes the baby to be so large?” The nurse’s response is based on the understanding that fetal
    macrosomia is usually related to which of the following?
63. Family history of large infants.
64. Fetal anomalies.
65. Maternal hyperglycemia.
66. Maternal hypertension.

Answer 62

62. 3. Maternal hyperglycemia and poor control of the mother’s diabetes mellitus have been
       implicated in fetal macrosomia. When the mother is hyperglycemic, large amounts of amino acids,
       free fatty acids, and glucose are transferred to the fetus. Although maternal insulin does not cross the
       placenta, the fetal pancreas responds by hypertrophy of the islet cells of the pancreas. The islet cells
       produce large amounts of insulin, which acts as a growth hormone. A family history of large infants
       usually is not the reason for large-for-gestational-age fetuses in diabetic mothers. Maternal
       hypertension is associated with small-for-gestational-age fetuses because of vasoconstriction of the
       maternal and placental blood vessels.
       CN: Physiological adaptation; CL: Apply

Question 63

63. With plans to breast-feed her neonate, a pregnant client with insulin-dependent diabetes asks
    the nurse about insulin needs during the postpartum period. Which of the following statements about
    postpartal insulin requirements for breast-feeding mothers should the nurse include in the
    explanation?
64. They fall significantly in the immediate postpartum period.2. They remain the same as during the labor process.
65. They usually increase in the immediate postpartum period.
66. They need constant adjustment during the first 24 hours.

Answer 63

63. 1. Insulin needs fall significantly for the first 24 hours postpartum because the client has
       usually been on nothing-by-mouth status for a period of time during labor and the labor process has
       used maternal glycogen stores. If the client breast-feeds, lower blood glucose levels decrease the
       insulin requirements. With insulin resistance gone, the client commonly needs little or no insulin
       during the immediate postpartum period. Although the need for insulin decreases during the
       intrapartum period, the insulin requirements fall further during the first 24 hours postpartum. After the
       first 24 hours postpartum, insulin requirements may fluctuate markedly, needing adjustment during the
       next few days as the mother’s body returns to a nonpregnant state.
       CN: Pharmacological and parenteral therapies; CL: Create

Question 64

The Pregnant Client with Heart Disease
64. After instruction of a primigravid client at 8 weeks’ gestation diagnosed with class I heart
disease about self-care during pregnancy, which of the following client statements would indicate the
need for additional teaching?
1. “I should avoid being near people who have a cold.”
2. “I may be given antibiotics during my pregnancy.”
3. “I should reduce my intake of protein in my diet.”
4. “I should limit my salt intake at meals.”

Answer 64

The Pregnant Client with Heart Disease
64. 3. The client needs a diet that is adequate in protein and calories to prevent anemia, which can
place additional strain on the cardiac system, further compromising the client’s cardiac status. The
client should avoid contact with people who have infections because of the increased risk for
developing endocarditis. The client may need antibiotics during the pregnancy to prevent
endocarditis. Limiting sodium intake can help to prevent excessive expansion of blood volume and
decrease cardiac workload.
CN: Reduction of risk potential; CL: Evaluate

Question 65

65. While caring for a primigravid client with class II heart disease at 28 weeks’ gestation, the
    nurse would instruct the client to contact her primary health care provider immediately if the client
    experiences which of the following?
66. Mild ankle edema.
67. Emotional stress on the job.
68. Weight gain of 1 lb (0.45 kg) in 1 week.
69. Increased dyspnea at rest.

Answer 65

65. 4. Increased dyspnea at rest must be reported immediately because it may be indicative of
       increasing congestive heart failure. Mild ankle edema in the third trimester is a common finding.
       However, generalized or pitting edema, suggesting increasing congestive heart failure, must be
       reported immediately. Emotional stress on the job increases cardiac demand. However, it needs to bereported only if the client experiences symptoms, such as palpitations or irregular heart rate,
       indicating heart failure related to the increased stress. Weight gain of 1 lb (0.45 kg) per week is a
       normal finding during the third trimester.
       CN: Reduction of risk potential; CL: Apply

Question 66

66. When developing the collaborative plan of care with the health care provider for a
    multigravid client at 10 weeks’ gestation with a history of cardiac disease who was being treated with
    digitalis therapy before this pregnancy, the nurse should instruct the client about which of the
    following regarding the client’s drug therapy regimen?
67. Need for an increased dosage.
68. Continuation of the same dosage.
69. Switching to a different medication.
70. Addition of a diuretic to the regimen.

Answer 66

66. 2. Unless the client has cardiac decompensation during the pregnancy, she will most likely be
       able to continue taking the same dose of medication. The client may be prescribed prophylactic
       antibiotics, particularly if she has had rheumatic fever. The medication would be switched only if
       digitalis toxicity occurs. A diuretic is added only if congestive heart failure is not controlled by
       sodium and activity restrictions.
       CN: Management of care; CL: Apply

Question 67

67. Which of the following anticoagulants would the nurse expect to administer when caring for a
    primigravid client at 12 weeks’ gestation who has class II cardiac disease due to mitral valve
    stenosis?
68. Heparin.
69. Warfarin.
70. Enoxaparin.
71. Ardeparin.

Answer 67

67. 1. Although there is no completely safe anticoagulant therapy during pregnancy, heparin is
       typically the drug of choice. Warfarin, a pregnancy category D drug, can cause fetal malformations.
       Enoxaparin is sometimes used, but clients are typically switched to heparin near labor because
       enoxaparin used along with spinal or epidural anesthesia presents an increased risk of bleeding in the
       epidural or spinal space. Ardeparin also can cause fetal malformations.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 68

68. A primigravid client with class II heart disease who is visiting the clinic at 8 weeks'
gestation tells the nurse that she has been maintaining a low-sodium, 1,800-cal diet. Which of the
following instructions should the nurse give the client?
1. Avoid folic acid supplements to prevent megaloblastic anemia.
2. Severely restrict sodium intake throughout the pregnancy.
3. Take iron supplements with milk to enhance absorption.
4. Increase caloric intake to 2,200 cal daily to promote fetal growth.

Answer 68

68. 4. The client can continue a low-sodium diet but should increase the caloric intake to 2,200
       cal daily to provide adequate nutrients to support fetal growth and development. Folic acid
       supplements, a standard component of care, are used to prevent folic acid deficiency, which is
       associated with megaloblastic anemia during pregnancy. Severe restriction of sodium intake is not
       recommended because sodium is necessary to maintain fluid volume. Iron supplements should be
       taken with acidic foods and fluids (eg, citrus juices) for maximum absorption. Milk decreases the
       absorption of iron.
       CN: Reduction of risk potential; CL: Apply

Question 69

The Client with an Ectopic Pregnancy
69. On arrival at the emergency department, a client tells the nurse that she suspects that she may
be pregnant but has been having a small amount of bleeding and has severe pain in the lower
abdomen. The client’s blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse
notifies the primary health care provider immediately because of the possibility of:
1. Ectopic pregnancy.
2. Abruptio placentae.
3. Gestational trophoblastic disease.
4. Complete abortion.

Answer 69

The Client with an Ectopic Pregnancy
69. 1. The client’s signs and symptoms indicate a probable ectopic pregnancy, which can be
confirmed by ultrasound examination or by culdocentesis. The primary health care provider is
notified immediately because hypovolemic shock may develop without external bleeding. Once the
fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae
would be manifested by a board-like uterus in the third trimester. Gestational trophoblastic disease
would be suspected if the client exhibited no fetal heart rate and symptoms of pregnancy-induced
hypertension before 20 weeks’ gestation. A client with a complete abortion would exhibit a normal
pulse and blood pressure with scant vaginal bleeding.
CN: Physiological adaptation; CL: Analyze

Question 70

70. The nurse is assessing a multigravid client at 12 weeks’ gestation who has been admitted to
    the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which of the
    following should the nurse obtain about the client’s history? Select all that apply.
71. History of sexually transmitted infections.
72. Number of sexual partners.
73. Last menstrual period.
74. Cesarean section.
75. Contraceptive use.

Answer 70

70. 1,2,3,5. The client may be experiencing an ectopic pregnancy. Contributing factors to an
    ectopic pregnancy include a prior history of sexually transmitted infection that can scar the fallopian
    tubes. Multiple sex partners increase the risk of sexually transmitted infections. Knowledge of the
    client’s last menstrual period and contraceptive use may support or rule out the possibility of an
    ectopic pregnancy. The client’s history of cesarean sections would not contribute information valuable
    to the client’s current situation or potential diagnosis of ectopic pregnancy.
    CN: Reduction of risk potential; CL: Analyze

Question 71

71. Before surgery to remove an ectopic pregnancy and the fallopian tube, which of the following
    would alert the nurse to the possibility of tubal rupture?
72. Amount of vaginal bleeding and discharge.
73. Falling hematocrit and hemoglobin levels.
74. Slow, bounding pulse rate of 80 bpm.
75. Marked abdominal edema.

Answer 71

71. 2. Falling hematocrit and hemoglobin levels indicate shock, which occurs if the tube ruptures.
       Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain
       and referred shoulder pain. The amount of vaginal bleeding that is evident is a poor estimate of actual
       blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready
       pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse.
       Abdominal edema is a late sign of a tubal rupture in ectopic pregnancy.
       CN: Reduction of risk potential; CL: Analyze

Question 72

72. A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for
    emergency surgery. In addition to monitoring the client’s blood pressure before surgery, which of the
    following would the nurse assess?
73. Uterine cramping.
74. Abdominal distention.
75. Hemoglobin and hematocrit.
76. Pulse rate.

Answer 72

72. 4. Fallopian tube rupture is an emergency situation because of extensive bleeding into the
       peritoneal cavity. Shock soon develops if precautionary measures are not taken. The nurse readying a
       client for surgery should be especially careful to monitor blood pressure and pulse rate for signs of
       impending shock. The nurse should be prepared to administer fluids, blood, or plasma expanders as
       necessary through an intravenous line that should already be in place. Because the fertilized ovum has
       implanted outside the uterus, uterine cramping is unlikely. However, abdominal tenderness or knife-
       like pain may occur. Abdominal fullness may be present, but abdominal distention is rare unless
       peritonitis has developed. Although the hemoglobin and hematocrit may be checked routinely before
       surgery, the laboratory results may not truly reflect the presence or degree of acute hemorrhage.
       CN: Reduction of risk potential; CL: Analyze

Question 73

73. A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic
    pregnancy. When obtaining the client’s history, which of the following would be most important to
    identify as a predisposing factor?
74. Urinary tract infection.
75. Marijuana use during pregnancy.
76. Episodes of pelvic inflammatory disease.
77. Use of estrogen-progestin contraceptives.

Answer 73

73. 3. Anything that causes a narrowing or constriction in the fallopian tubes so that a fertilized
       ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy.
       Pelvic inflammatory disease is the most common cause of constricted or narrow tubes.
       Developmental defects are other possible causes. Ectopic pregnancy is not related to urinary tract
       infections. Use of marijuana during pregnancy is not associated with ectopic pregnancy, but its use
       can result in cognitive reduction if the mother’s use during pregnancy is extensive. Progestin-only
       contraceptives and intrauterine devices have been associated with ectopic pregnancy.
       CN: Physiological adaptation; CL: Analyze

Question 74

74. A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The
    nurse anticipates that, because the client’s fallopian tube has not yet ruptured, which of the following
    may be prescribed?
75. Progestin contraceptives.2. Medroxyprogesterone.
76. Methotrexate.
77. Dyphylline.

Answer 74

74. 3. Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by
       leucovorin. This chemotherapeutic agent attacks the fast-growing zygote and trophoblast cells. RU-
       486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine
       whether the tube is still patent. Progestin-only contraceptives and medroxyprogesterone are
       ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 75

The Pregnant Gravidarum Client with Hyperemesis

75. After instruction of a primigravid client at 8 weeks’ gestation about measures to overcome
    early morning nausea and vomiting, which of the following client statements indicates the need for
    additional teaching?
76. “I’ll eat dry crackers or toast before arising in the morning.”
77. “I’ll drink adequate fluids separate from my meals or snacks.”
78. “I’ll eat two large meals daily with frequent protein snacks.”
79. “I’ll snack on a small amount of carbohydrates throughout the day.”

Answer 75

The Pregnant Client with Hyperemesis Gravidarum

75. 3. The client needs further instructions when she says she should eat two meals a day with
       frequent protein snacks to decrease nausea and vomiting. The client should eat more frequent, smaller
       meals, with frequent carbohydrate snacks to decrease nausea and vomiting. Eating dry crackers or
       toast before arising, consuming fluids separately from meals, and avoiding greasy or spicy foods may
       also help to decrease nausea and vomiting.
       CN: Basic care and comfort; CL: Evaluate

Question 76

76. A multigravid client thought to be at 14 weeks’ gestation reports that she is experiencing such
    severe morning sickness that she “has not been able to keep anything down for a week.” The nurse
    should assess for signs and symptoms of which of the following?
77. Hypercalcemia.
78. Hypobilirubinemia.
79. Hypokalemia.
80. Hyperglycemia.

Answer 76

76. 3. Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive
       perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis,
       and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine.Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to
       hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients
       with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of
       bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake
       of food and fluids, decreased metabolism of nutrients, and excessive vomiting.
       CN: Reduction of risk potential; CL: Analyze

Question 77

77. A multigravid client is admitted at 16 weeks’ gestation with a diagnosis of hyperemesis
    gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be
    related to high levels of which of the following hormones?
78. Progesterone.
79. Estrogen.
80. Somatotropin.
81. Aldosterone.

Answer 77

77. 2. Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen
       and human chorionic gonadotropin levels or to trophoblastic activity or gonadotropin production.
       Hyperemesis is also associated with infectious conditions, such as hepatitis or encephalitis, intestinal
       obstruction, peptic ulcer, and hydatidiform mole. Progesterone is a relaxant used during pregnancy
       and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is
       a male hormone.
       CN: Physiological adaptation; CL: Apply

Question 78

78. The primary health care provider prescribes 1,000 mL of Ringer’s Lactate intravenously over
    an 8-hour period for a 29-year-old primigravid client at 16 weeks’ gestation with hyperemesis. The
    drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute?
    ___________________________________ gtts/min.

Answer 78

8. 25 gtts/min

CN: Pharmacological and parenteral therapies; CL: Apply

Question 79

The Client with a Gestational Trophoblastic
Disease
79. A client at 15 weeks’ gestation is admitted with dark brown vaginal bleeding and continuous
nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should
prepare to do which of the following?
1. Transfer the client to the antenatal unit.
2. Keep the client NPO for 24 hours.
3. Administer magnesium sulfate.
4. Obtain an ultrasound.

Answer 79

The Client with a Gestational Trophoblastic Disease

79. 4. The nurse should prepare the client for an ultrasound to determine the cause of the
       symptoms. Elevated blood pressure at this point in the pregnancy could indicate chronic hypertension
       as well as hydatidiform mole. The fundal height of 19 cm is higher than is typically found at 15
       weeks’ gestation and is indicative of a molar pregnancy (hydatidiform mole). The dark brown vaginal bleeding in isolation could indicate an abortion but when placed in context of the other symptoms is likely related to a hydatidiform mole. The continuous nausea and vomiting is abnormal at this point in the pregnancy and can be a result of the high levels of progesterone from a molar pregnancy. There is no fetus involved; the blood pressure elevation and the continuous nausea and vomiting will resolve with evacuation of the mole, negating the need for magnesium sulfate therapy and placing the client on NPO status.
       CN: Reduction of risk potential; CL: Synthesize

Question 80

80. A 38-year-old client at about 14 weeks’ gestation is admitted to the hospital with a diagnosis
    of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and
    symptoms of which of the following?
81. Pregnancy-induced hypertension.
82. Gestational diabetes.
83. Hypothyroidism.
84. Polycythemia.

Answer 80

80. 1. Hydatidiform mole is suspected when the following are present: pregnancy-induced
       hypertension before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia,
       absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected
       for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is
       related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with
       hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform
       mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and
       fetus from cardiac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia
       from blood loss is associated with molar pregnancies.
       CN: Reduction of risk potential; CL: Analyze

Question 81

81. After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for
    signs and symptoms of which of the following would be most important?
82. Urinary tract infection.
83. Hemorrhage.
84. Abdominal distention.
85. Chorioamnionitis.

Answer 81

81. 2. After D&C to evacuate a molar pregnancy, the nurse should assess the client’s vital signs
       and monitor for signs of hemorrhage, because the surgical procedure may have traumatized the uterine
       lining, leading to hemorrhage. Urinary tract infections, not common after evacuation of a molarpregnancy, are most commonly related to urinary catheterization. Typically, urinary catheters are not
       used during evacuation of a molar pregnancy. The client should not experience abdominal distention,
       because the contents of the uterus have been removed. Chorioamnionitis is an inflammation of the
       amniotic fluid membranes. With complete mole, no embryonic or fetal tissue or membranes are
       present.
       CN: Reduction of risk potential; CL: Analyze

Question 82

82. When preparing a multigravid client who has undergone evacuation of a hydatidiform mole
    for discharge, the nurse explains the need for follow-up care. The nurse determines that the client
    understands the instruction when she says that she is at risk for developing which of the following?
83. Ectopic pregnancy.
84. Choriocarcinoma.
85. Multifetal pregnancies.
86. Infertility.

Answer 82

82. 2. A client who has had a hydatidiform mole removed should have regular checkups to rule
       out the presence of choriocarcinoma, which may complicate the client’s clinical picture. The client’s
       human chorionic gonadotropin (hCG) levels are monitored for 1 year. During this time, she should be
       advised not to become pregnant because this would be reflected in rising hCG levels. Ectopic or
       multifetal pregnancy is not associated with hydatidiform mole. Women who have molar pregnancies
       have fertility rates similar to the general population.
       CN: Reduction of risk potential; CL: Synthesize

Question 83

83. After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid
    client asks the nurse when she can become pregnant again. The nurse would advise the client not to
    become pregnant again for at least which of the following time spans?
84. 6 months.
85. 12 months.
86. 18 months.
87. 24 months.

Answer 83

83. 2. A client who has experienced a molar pregnancy is at risk for development of
       choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels.
       Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7
       weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients
       should have a pelvic examination and a blood test for hCG titers every month for 6 months and then
       every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing
       levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG
       levels are negative, the client is theoretically free of the risk of a malignancy developing and could
       plan another pregnancy.
       CN: Reduction of risk potential; CL: Apply

Question 84

The Pregnant Complications Client with Miscellaneous

84. The nurse is working with four clients on the obstetrical unit. Which client will be the highest
    priority for a cesarean section?
85. Client at 40 weeks’ gestation whose fetus weighs 8 lb (3,629 g) by ultrasound estimate.
86. Client at 37 weeks’ gestation with fetus in ROP position.
87. Client at 32 weeks’ gestation with fetus in breech position.
88. Client at 38 weeks’ gestation with active herpes lesions.

Answer 84

The Pregnant Client with Miscellaneous Complications
84. 4. Herpes simplex virus can be transmitted to the infant during a vaginal birth. The neonatal
effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or
secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3
months after the lesion has healed. The client carrying an infant weighing 8 lb (3,629 g) will be given
a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will
have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech
position still has many weeks to change positions before being at term. At 7 months’ gestation, the
breech position is not a concern.
CN: Physiological adaptation; CL: Evaluate

Question 85

85. The nurse notices that a client who has just given birth is short of breath, ashen in color, and
    begins to cough. She becomes limp on the birthing table. At last assessment 1⁄2 hour ago, her
    temperature was 98 (36.7), pulse 78, respirations 16. Determine the nursing actions in the order they
    should occur.
86. Open airway using head tilt-chin lift.
87. Ask staff to activate emergency response system.
88. Establish unresponsiveness.
89. Give 2 breaths.
90. Begin compressions.

Answer 85

85.
3. Establish unresponsiveness.
2. Ask staff to activate emergency response system.
5. Begin compressions.1. Open airway using head tilt-chin lift.
4. Give 2 breaths.
The client’s actions indicate distress and the nurse should initiate emergency procedures. The
nurse should first establish unresponsiveness and then ask staff to activate the emergency response
system. Next, the nurse should follow CAB’s of CPR. The nurse should check the pulse and begin
CPR. Then after 30 compressions the nurse should assure the open airway, and give 2 breaths.
CN: management of care; CL: Synthesize

Question 86

86. A client in sickle cell crisis has been hospitalized during her pregnancy. After giving
    discharge instructions, the nurse determines the client needs further teaching when she states which of
    the following?
87. “I will need more frequent appointments during the remainder of the pregnancy.”
88. “Signs of any type of infection must be reported immediately.”
89. “At the earliest signs of a crisis, I need to seek treatment.”
90. “I have this disease because I don’t eat enough food with iron.”

Answer 86

86. 4. Sickle cell disease is an autosomal recessive disorder requiring both parents to have a
       sickle cell trait to pass the disease to a child. Deoxygenated hemoglobin cells assume a sickle shape
       and obstruct tissues. Tissue obstruction causes hypoxia to the area (vaso-occlusion) and results in
       pain, called sickle cell crisis. This type of anemia is an inherited disorder; it is not caused by lack of
       iron in the diet. Self-monitoring for any type of infections or sickle cell crisis and increased
       frequency of antenatal care visits are part of the teaching plan of care.
       CN: Physiological adaptation; CL: Evaluate

Question 87

87. A laboring client at –2 station has a spontaneous rupture of the membranes and a cord
    immediately protrudes from the vagina. The nurse should first:
88. Place gentle pressure upward on the fetal head.
89. Place the cord back into the vagina to keep it moist.
90. Begin oxygen by face mask at 8 to 10 L/min.
91. Turn the client on her left side.

Answer 87

87. 1. The nurse should place a hand on the fetal head and provide gentle upward pressure to
       relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The
       cord should never be placed back into the vagina because doing so may further compress it.
       Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure
       is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates
       better perfusion to the mother but, until the compression on the cord is relieved, the increased oxygen
       will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be
       position changes to increase perfusion to the infant by relieving cord compression.
       CN: management of care; CL: Synthesize

Question 88

88. A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history,
which of the following factors places a client at risk for cord prolapse? Select all that apply.
1. 2 station.
2. Low birth weight infant.
3. Rupture of membranes.
4. Breech presentation.
5. Prior abortion.
6. Low lying placenta.

Answer 88

88. 1,2,3,4. Having the fetus at a negative station places the client at risk for a cord prolapse.
    With a negative station, there is room between the fetal head and the maternal pelvis for the cord to
    slip through. A small infant is more mobile within the uterus and the cord can rest between the fetus
    and the inside of the uterus or below the fetal head. With a large infant, the head is usually in a vertex
    presentation and occludes the lower portion of the uterus, preventing the cord from slipping by. When
    membranes rupture, the cord can be swept through with the amniotic fluid. In a breech presentation,
    the fetal head is in the fundus and smaller portions of the fetus settle into the lower portion of the
    uterus, allowing the cord to lie beside the fetus. Prior abortion and a low lying placenta have no
    correlation to cord prolapse.
    CN: Physiological adaptation; CL: Analyze

Question 89

89. A woman who has given birth to a healthy neonate is being discharged. As part of discharge
    teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage
    and notify the health care provider about:
90. Bleeding that becomes lighter each day
91. Clots the size of golf balls
92. Saturating a pad in an hour
93. Lochia that lasts longer than 1 week

Answer 89

89. 3. A postpartum client who saturates a pad in an hour or less at any time in the postpartum
       period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes
       from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a
       fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up
       to 6 weeks postpartum.CN: Health promotion and maintenance; CL: Create

Question 90

90. A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to
    the client that she will receive Rho (D) Immune Globulin (RhoGAM). The nurse determines that the
    client understands the purpose of RhoGAM when she states:
91. “RhoGAM will protect my next baby if it is Rh-negative.”
92. “RhoGAM will prevent antibody formation in my blood.”
93. “RhoGAM will be given to prevent German measles.”
94. “RhoGAM will be used to prevent bleeding in my newborn.”

Answer 90

90. 2. RhoGAM is given to new mothers who are Rh-negative and not previously sensitized and
       who have given birth to an Rh-positive infant. RhoGAM must be given within 72 hours of the birth of
       the infant because antibody formation begins at that time. The vaccine is used only when the mother
       has borne an Rh-positive infant—not an Rh-negative infant. RhoGAM does not prevent German
       measles and is not given to a newborn.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 91

91. A client at 4 weeks postpartum tells the nurse that she can’t cope any longer and is
    overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The
    mother does not remember when she last bathed the baby and states she does not want to care for the
    infant. The nurse should encourage the client and her husband to call their health care provider
    because the mother should be evaluated further for:
92. Postpartum blues.
93. Postpartum depression.
94. Poor bonding.
95. Infant abuse.

Answer 91

91. 2. The client is experiencing and verbalizing signs of postpartum depression, which usually
       appears at about 4 weeks postpartum but can occur at any time within the first year after birth. It is
       more severe and lasts longer than postpartum blues, also called “baby blues.” Baby blues are the
       mildest form of depression and are seen in the later part of the first week after birth. Symptoms
       usually disappear shortly. Depression may last several years and is disabling to the woman. Poor
       bonding may be seen at any time but commonly becomes evident as the mother begins interacting with
       the infant shortly after birth. Infant abuse may take the form of neglect or injuries to the infant. A
       depressed mother is at risk for injuring or abusing her infant.
       CN: Reduction of risk potential; CL: Synthesize

Question 92

92. The nurse and a nursing assistant are caring for clients in a birthing center. Which of the
    following tasks should the nurse delegate to the nursing assistant? Select all that apply.
93. Removing a Foley catheter from a preeclamptic client.
94. Assisting an active labor client with breathing and relaxation.
95. Ambulating a postcesarean client to the bathroom.4. Calculating hourly IV totals for a preterm labor client.
96. Intake and output catheterization for culture and sensitivity.
97. Calling a report of normal findings to the health care provider.

Answer 92

92. 2,3. The nursing assistant could assist the client with breathing and relaxation, and ambulate
    the postcesarean client to the bathroom. Removing a Foley catheter would also involve assessment of
    bladder status and totaling the intake and output and would be a nursing responsibility. Calculating the
    hourly IV totals for a preterm labor client would involve assessments that require nursing expertise.
    In-and-out catheterization, a sterile procedure, and calling reports to health care providers, which
    requires gathering and analysis of data, are responsibilities of the nurse.
    CN: Management of care; CL: Evaluate

Question 93

Managing Care Quality and Safety

93. Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which
    client should the nurse see first?
94. A client at 13 weeks’ gestation experiencing nausea and vomiting three times a day with +1
    ketones in her urine.
95. A client at 37 weeks’ gestation who is an insulin-dependent diabetic and experiencing 3 to 4
    fetal movements per day.
96. A client at 32 weeks’ gestation who has preeclampsia and +3 proteinuria who is returning for
    evaluation of epigastric pain.
97. A client at 17 weeks’ gestation who is not feeling fetal movement at this point in her pregnancy

Answer 93

Managing Care Quality and Safety
93. 3. A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which
would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at
13 weeks’ gestation with nausea and vomiting is a concern because the presence of ketones indicates
that her body does not have glucose to break down. However, this situation is a lower priority than
the preeclamptic client or the insulin-dependent diabetic. The insulin-dependent diabetic is a high
priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal
movements in 12 hours can be considered normal. (The client may need additional testing to further
evaluate fetal well-being.) The client who is at 17 weeks’ gestation may be too early in her pregnancy
to experience fetal movement and would be the last person to be seen.
CN: Management of care; CL: Evaluate

Question 94

94. The nurse is planning care for a group of pregnant clients. Which of the following clients
    should be referred to a health care provider immediately?
95. A woman who is at 10 weeks’ gestation, is having nausea and vomiting, and has +1 ketones in
    her urine.
96. A woman who is at 37 weeks’ gestation and has insulin-dependent diabetes experiencing two
    to three hyperglycemic episodes weekly.
97. A woman at 32 weeks’ gestation and is preeclamptic with +3 proteinuria.
98. A woman at 15 weeks’ gestation who reports she has not felt fetal movement.

Answer 94

94. 3. The nurse should refer the preeclamptic client with 3+ proteinuria to a health care provider.
       The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks’
       gestation with insulin-dependent diabetes who has experienced hypoglycemic episodes in the past
       week can be managed with food and glucose tablets until the client can obtain an appointment with the
       care provider. The client at 10 weeks’ gestation with nausea and vomiting and +1 ketones should also
       be seen by a health care provider, but at this point this client is uncomfortable but her life is not in
       danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancyand this would not be considered a problem that requires immediate referral to a health care
       provider.
       CN: Management of care; CL: Evaluate

Question 95

95. A client with pregnancy-induced hypertension is to receive magnesium sulfate to run at 3 g/h
    with normal saline to maintain the total IV rate at 125 mL/h. The nurse giving end of shift report stated
    that the client’s blood pressures have been elevated during the night. The oncoming nurse checked the
    client and found magnesium sulfate running at 2 g/h. Identify the nursing actions to be taken from first
    to last.
96. Notify the primary health care provider of the incident.
97. Assess the client’s current status.
98. Correct the IV rates.
99. Initiate an incident report.

Answer 95

3. Correct the IV rates.
4. Assess the client’s current status.
5. Notify the primary health care provider of the incident.
6. Initiate an incident report.
   The nurse should first change the IV magnesium sulfate and normal saline infusion rates, and then
   assess the current status of the client. The nurse should then notify the primary health care provider to
   explain the error and report the action taken. A medication error has occurred and the nurse will need
   to initiate an incident report.
   CN: Management of care; CL: Synthesize

Question 96

96. As the nurse enters the room of a newly admitted primigravid client diagnosed with severepreeclampsia, the client begins to experience a seizure. The nurse should do which in order of
priority from first to last?
1. Call for immediate assistance.
2. Turn the client to her side.
3. Assess for ruptured membranes.
4. Maintain airway.

Answer 96

96.
1. Call for immediate assistance.
3. Maintain airway.
2. Turn the client to her side.
4. Assess for ruptured membranes.
If a client begins to have a seizure, the first action by the nurse is to remain with the client and call
for immediate assistance. Next, the nurse should turn the client to her side and then maintain the
airway by keeping the neck hyperextended. When the seizure is over, the nurse should assess the
client for ruptured membranes and the fetal status.
CN: Management of care; CL: Synthesize

Question 97

97. The nurse is receiving shift report on four clients on an antenatal unit. The four clients are:
    (1) a 35-week-gestation mother with severe pre-eclampsia started on a maintenance dose of
    magnesium sulfate 1 hour ago; (2) a 30-week-gestation patient with preterm labor on oral nifedipine
    and having no contractions in 6 hours; (3) a hyperemesis client with emesis four times in the past 12
    hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure
    during change of shift report. In what order should the nurse see these clients?
98. Evaluate the client with pre-eclampsia for maternal and fetal tolerance of magnesium sulfate
    and the labor pattern.
99. Assess the client with preterm labor for tolerance of nifedipine and the labor pattern.
100. Evaluate the placenta previa client without an exam.
101. Assess the hyperemesis client for nausea for further emesis, or dehydration.

Answer 97

97. 3,1,4,2. The first action taken should be to evaluate the placenta previa patient who has pelvic
    pressure. The pelvic pressure may be caused by a fetal head creating pressure in the pelvis indicating
    a potential birth. This patient should be evaluated without a pelvic exam and then consult with the
    physician. A vaginal exam is contraindicated as it may stimulate bleeding of the placenta. The second
    action would be to complete an assessment on the client with pre-eclampsia and her fetus to evaluatefor tolerance and effectiveness of the magnesium sulfate. The hyperemesis patient needs to be
    evaluated for hydration status and for medication. The preterm labor client is stable on the oral
    medication and should be seen last.
    CN: Management of care; CL: apply