Unit I-Labor and Delivery Complications

Question 1

In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the patient states:
a. “I will need to increase my insulin dosage during the first 3 months of pregnancy.”
b. “Insulin dosage will likely need to be increased during the second and third
trimesters.”
c. “Episodes of hypoglycemia are more likely to occur during the first 3 months.”
d. “Insulin needs should return to normal within 7 to 10 days after birth if I am
bottle-feeding.”

Answer 1

ANS: A
Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. “Insulin dosage will likely need to be increased during the second and third trimesters,” “Episodes of hypoglycemia are more likely to occur during the first 3 months,” and “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding” are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy.

Question 2

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with:

a. frequent episodes of maternal hypoglycemia.
b. congenital anomalies in the fetus.
c. polyhydramnios.
d. hyperemesis gravidarum.

Answer 2

ANS: B
Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contributes to hypoglycemia.

Question 3

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:

a. mother’s age.
b. number of years since diabetes was diagnosed.c. amount of insulin required prenatally.
d. degree of glycemic control during pregnancy.

Answer 3

ANS: D

Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes

Question 4

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:

a. macrosomia.
b. congenital anomalies of the central nervous system.
c. preterm birth.
d. low birth weight

Answer 4

ANS: A
Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.

Question 5

A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 lbs less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time?

a. Deficient fluid volume
b. Imbalanced nutrition: less than body requirements
c. Imbalanced nutrition: more than body requirements
d. Disturbed sleep pattern

Answer 5

ANS: B
This patient’s clinical cues include weight loss, which would support the nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support the nursing diagnosis of Deficient fluid volume. This patient reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the patient reports nervousness based on the patient’s other clinical symptoms the most appropriate nursing diagnosis would be Imbalanced nutrition: less than body requirements.

Question 6

Maternal phenylketonuria (PKU) is an important health concern during pregnancy because:

a. it is a recognized cause of preterm labor.
b. the fetus may develop neurologic problems.
c. a pregnant woman is more likely to die without dietary control.
d. women with PKU are usually retarded and should not reproduce.

Answer 6

ANS: B
Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of uncertain etiology, or who have given birth to microcephalic infants.

Question 7

In terms of the incidence and classification of diabetes, maternity nurses should know that:
a. type 1 diabetes is most common.
b. type 2 diabetes often goes undiagnosed.
c. gestational diabetes mellitus (GDM) means that the woman will be receiving
insulin treatment until 6 weeks after birth.
d. type 1 diabetes may become type 2 during pregnancy.

Answer 7

ANS: B
Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often
is not severe. Type 2 diabetes, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between type 1 and 2 diabetes.

Question 8

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that:
a. insulin crosses the placenta to the fetus only in the first trimester, after which the
fetus secretes its own.
b. women with insulin-dependent diabetes are prone to hyperglycemia during the first
trimester because they are consuming more sugar.
c. during the second and third trimesters, pregnancy exerts a diabetogenic effect that
ensures an abundant supply of glucose for the fetus.
d. maternal insulin requirements steadily decline during pregnancy.

Answer 8

ANS: C
Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the 10th week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.

Question 9

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that:

a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
b. Hydramnios occurs approximately twice as often in diabetic pregnancies.
c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies.
d. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

Answer 9

ANS: A
Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

Question 10

The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc:

a. is now done for all pregnant women, not just those with or likely to have diabetes.
b. is a snapshot of glucose control at the moment.
c. would be considered evidence of good diabetes control with a result of 5% to 6%.
d. is done on the patient’s urine, not her blood.

Answer 10

ANS: C
A score of 5% to 6% indicates good control. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood.

Question 11

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)?
a. 75 mg/dL before lunch. This is low; better eat now.
b. 115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time.
c. 115 mg/dL 2 hours after lunch; This is too high; it is time for insulin.
d. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack
before going to sleep.

Answer 11

ANS: D
60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 70 mg/dL. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL.

Question 12

A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding?

a. Hyperthyroidism
b. Phenylketonuria (PKU)
c. Hypothyroidism
d. Thyroid storm

Answer 12

ANS: B
PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine. A woman with hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism.

Question 13

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include:

a. a regular heart rate and hypertension.
b. an increased urinary output, tachycardia, and dry cough.
c. shortness of breath, bradycardia, and hypertension.
d. dyspnea; crackles; and an irregular, weak pulse.

Answer 13

ANS: D
Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, rapid pulse; rapid respirations; a moist, frequent cough; generalized edema; increasing fatigue; and cyanosisofthelipsandnailbeds.NAURreSgINulGaTrBh.eCaOrtMrateandhypertensionarenotgenerally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation, but increased urinary output and a dry cough would not. Shortness of breath would indicate cardiac decompensation, but bradycardia and hypertension would not.

Question 14

While providing care in an obstetric setting, the nurse should understand that after birth care of the woman with cardiac disease:

a. is the same as that for any pregnant woman.
b. includes rest, stool softeners, and monitoring of the effect of activity.
c. includes ambulating frequently, alternating with active range of motion.
d. includes limiting visits with the infant to once per day.

Answer 14

ANS: B
Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the after birth period is tailored to the woman’s functional capacity. The woman will be on bed rest to conserve energy and reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

Question 15

A woman with asthma is experiencing a after birth hemorrhage. Which drug would not be used to treat her bleeding because it may exacerbate her asthma?

a. Pitocin
b. Nonsteroidal anti-inflammatory drugs (NSAIDs)
c. Hemabate
d. Fentanyl

Answer 15

ANS: C
Prostaglandin derivatives should not be used to treat women with asthma because they may exacerbate symptoms. Pitocin would be the drug of choice to treat this woman’s bleeding because it would not exacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding.

Question 16

The use of methamphetamine (meth) has been described as a significant drug problem in the United States. In order to provide adequate nursing care to this patient population the nurse must be cognizant that methamphetamine:

a. is similar to opiates.
b. is a stimulant with vasoconstrictive characteristics.
c. should not be discontinued during pregnancy.
d. is associated with a low rate of relapse.

Answer 16

ANS: B
Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and
are used similarly. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is very high.

Question 17

Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to statistics, how often does cystic fibrosis occur in Caucasian live births?

a. 1 in 100
b. 1 in 1200
c. 1 in 2500
d. 1 in 3000

Answer 17

ANS: D

Cystic fibrosis occurs in about 1 in 3000 Caucasian live births.

Question 18

Which heart condition is not a contraindication for pregnancy?

a. Peripartum cardiomyopathy
b. Eisenmenger syndrome
c. Heart transplantd. All of these contraindicate pregnancy.

Answer 18

ANS: C
Pregnancy is contraindicated for peripartum cardiomyopathy and Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation.

Question 19

During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:

a. euglycemia.
b. rheumatic fever.
c. pneumonia.
d. cardiac decompensation.

Answer 19

ANS: D
Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not manifest with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation.

Question 20

NursescaringforantepartumwomNeUnRwSIiNthGTcaBr.dCiOaMcconditionsshouldbeawarethat:
a. stress on the heart is greatest in the first trimester and the last 2 weeks before labor.
b. women with Class II cardiac disease should avoid heavy exertion and any activity
that causes even minor symptoms.
c. women with Class III cardiac disease should have 8 to 10 hours of sleep every day
and limit housework, shopping, and exercise.
d. Women with Class I cardiac disease need bed rest through most of the pregnancy
and face the possibility of hospitalization near term.

Answer 20

ANS: B
Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32, when homodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less than ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can carry on limited normal activities with discretion, although they still need a good amount of sleep.

Question 21

As related to the care of the patient with anemia, the nurse should be aware that:

a. it is the most common medical disorder of pregnancy.
b. it can trigger reflex brachycardia.
c. the most common form of anemia is caused by folate deficiency.

d. thalassemia is a European version of sickle cell anemia.

Answer 21

ANS: A
Combined with any other complication, anemia can result in congestive heart failure. Reflex bradycardia is a slowing of the heart in response to the blood flow increases immediately after birth. The most common form of anemia is iron deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas.

Question 22

The most common neurologic disorder accompanying pregnancy is:

a. eclampsia.
b. Bell’s palsy.
c. epilepsy.
d. multiple sclerosis.

Answer 22

ANS: C
The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurologic disorder accompanying pregnancy. Bell’s palsy is a form of facial paralysis. Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth.

Question 23

With one exception, the safest pregnancy is one in which the woman is drug and alcohol free. For women addicted to opioids, ________________________ treatment is the current standard of care during pregnancy.

a. methadone maintenance
b. detoxification
c. smoking cessation
d. 4 Ps Plus

Answer 23

ANS: A
Methadone maintenance treatment (MMT) is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for opioid addiction treatment that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease rates of infections such as hepatitis B and C, HIV, and other sexually transmitted infections. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool designed specifically to identify pregnant women who need in-depth assessment related to substance abuse

Question 24

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?

a. Hypoglycemia
b. Hypercalcemia
c. Hypobilirubinemia d. Hypoinsulinemia

Answer 24

ANS: A
The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth and release large amounts of bilirubin into the neonate’s circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate presents with hyperinsulinemia.

Question 25

Which factor is known to increase the risk of gestational diabetes mellitus?

a. Underweight before pregnancy
b. Maternal age younger than 25 years
c. Previous birth of large infant
d. Previous diagnosis of type 2 diabetes mellitus

Answer 25

ANS: C
Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy

Question 26

Glucose metabolism is profoundly affected during pregnancy because:
a. pancreatic function in the islets of Langerhans is affected by pregnancy.
b. the pregnant woman uses glucose at a more rapid rate than the nonpregnant
woman.
c. the pregnant woman increases her dietary intake significantly.
d. placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

Answer 26

ANS: D
Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin is also broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.

Question 27

To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by:

a. eating six small equal meals per day.
b. reducing carbohydrates in her diet.
c. eating her meals and snacks on a fixed schedule.
d. increasing her consumption of protein.

Answer 27

ANS: C
Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.

Question 28

When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient:

a. eat six saltine crackers.
b. drink 8 ounces of orange juice with 2 tsp of sugar added.
c. drink 4 ounces of orange juice followed by 8 ounces of milk.
d. eat hard candy or commercial glucose wafers.

Answer 28

ANS: A
Crackers provide carbohydrates inNtUhReSfIoNrGmToBf.CpOoMlysaccharides. Orange juice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharide and orange juice is a monosaccharide. They will provide an increase in blood sugar but will not sustain the level. Hard candy or commercial glucose wafers provide only monosaccharides.

Question 29

Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin:

a. increases throughout pregnancy and the after birth period.
b. decreases throughout pregnancy and the after birth period.
c. varies depending on the stage of gestation.
d. should not change because the fetus produces its own insulin.

Answer 29

ANS: C
Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. The insulin needs change throughout the different stages of pregnancy.

Question 30

In caring for a pregnant woman with sickle cell anemia, the nurse is aware that signs and symptoms of sickle cell crisis include:

a. anemia.
b. endometritis.
c. fever and pain.
d. urinary tract infection

Answer 30

ANS: C
Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with sickle cell anemia are not iron deficient. Therefore, routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload. Women with sickle cell trait usually are at greater risk for after birth endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis. These women are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis

Question 31

Congenital anomalies can occur with the use of antiepileptic drugs (AEDs), including: (Select all that apply.)

a. cleft lip.
b. congenital heart disease.
c. neural tube defects.
d. gastroschisis.
e. diaphragmatic hernia.

Answer 31

ANS: A, B, C
Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Gastroschisis and diaphragmatic hernia are not associated with the use of AEDs

Question 32

Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. These complications include: (Select all that apply.)

a. atherosclerosis.
b. retinopathy.
c. IUFD.
d. nephropathy.
e. neuropathy.

Answer 32

ANS: A, B, D, EThese structural changes are most likely to affect a variety of systems, including the heart, eyes, kidneys, and nerves. Intrauterine fetal death (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.

Question 33

Autoimmune disorders often occur during pregnancy because a large percentage of women with an autoimmune disorder are of childbearing age. Identify all disorders that fall into the category of collagen vascular disease.

a. Multiple sclerosis
b. Systemic lupus erythematosus
c. Antiphospholipid syndrome
d. Rheumatoid arthritis
e. Myasthenia gravis

Answer 33

ANS: B, C, D, E
Multiple sclerosis is not an autoimmune disorder. This patchy demyelinization of the spinal cord may be a viral disorder. Autoimmune disorders (collagen vascular disease) make up a large group of conditions that disrupt the function of the immune system of the body. They include those listed, as well as systemic sclerosis.

Question 34

Women with hyperemesis gravidarum:
a. are a majority because 80% of all pregnant women suffer from it at some time.
b. have vomiting severe and persistent enough to cause weight loss, dehydration, and
electrolyte imbalance.
c. need intravenous (IV) fluid and nutrition for most of their pregnancy.
d. often inspire similar, milder symptoms in their male partners and mothers.

Answer 34

ANS: B
Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 80% of pregnant women experience nausea and vomiting, fewer than 1% (0.5%) proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is seldom needed for very long. Women suffering from this condition want sympathy because some authorities believe that difficult relationships with mothers and/or partners may be the cause.

Question 35

Because pregnant women may need surgery during pregnancy, nurses should be aware that:
a. the diagnosis of appendicitis may be difficult because the normal signs and
symptoms mimic some normal changes in pregnancy.
b. rupture of the appendix is less likely in pregnant women because of the close monitoring.
c. surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy.
d. when pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.

Answer 35

ANS: A
Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell count. Rupture of the appendix is two to three times more likely in pregnant women. Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy predisposes a woman to ovarian problems.

Question 36

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?

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

Answer 36

Ans B.Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.

Question 37

In caring for an immediate after birth patient, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:

a. disseminated intravascular coagulation (DIC).
b. amniotic fluid embolism (AFE).
c. hemorrhage.
d. HELLP syndrome.

Answer 37

ANS: A
The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman’s arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the after birth patient. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

Question 38

A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?

a. Blood pressure (BP) increase to 138/86 mm Hg.
b. Weight gain of 0.5 kg during the past 2 weeks.
c. A dipstick value of 3+ for protein in her urine.
d. Pitting pedal edema at the end of the day.

Answer 38

ANS: C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or in diastolic pressure of 15 mm Hg. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

Question 39

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman’s latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of:

a. eclampsia.
b. disseminated intravascular coagulation (DIC).
c. HELLP syndrome.
d. idiopathic thrombocytopenia.

Answer 39

ANS: C
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves
hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low
platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential
complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence
of low platelets of unknown cause and is not associated with preeclampsia.

Question 40

A woman with preeclampsia has a seizure. The nurse’s primary duty during the seizure is to:

a. insert an oral airway.
b. suction the mouth to prevent aspiration.
c. administer oxygen by mask.
d. stay with the patient and call for help.

Answer 40

ANS: D
If a patient becomes eclamptic, the nurse should stay her and call for help. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient’s head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the patient’s mouth. Oxygen would be administered after the convulsion has ended.

Question 41

A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The patient complains, “I’m so thirsty and warm.” The nurse:

a. calls for a stat magnesium sulfate level.
b. administers oxygen.
c. discontinues the magnesium sulfate infusion.
d. prepares to administer hydralazine.

Answer 41

ANS: C
The patient is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.

Question 42

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:

a. hydralazine.
b. magnesium sulfate bolus.
c. diazepam.
d. calcium gluconate

Answer 42

ANS: A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically, it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The patient is not currently displaying any signs or symptoms of magnesium toxicity.

Question 43

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:

a. eclamptic seizure.
b. rupture of the uterus.
c. placenta previa.
d. placental abruption.

Answer 43

ANS: D
Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.

Question 44

The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits:

a. a sleepy, sedated affect.
b. a respiratory rate of 10 breaths/min.
c. deep tendon reflexes of 2.
d. absent ankle clonus.

Answer 44

ANS: B
A respiratory rate of 10 breaths/min indicates that the patient is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the patient will most likely become sedated when the infusion is initiated. Deep tendon reflexes of two and absent ankle clonus are normal findings.

Question 45

The nurse caring for pregnant women must be aware that the most common medical
complication of pregnancy is:
a. hypertension.
b. hyperemesis gravidarum.
c. hemorrhagic complications.
d. infections.

Answer 45

ANS: A
Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common.

Question 46

Nurses should be aware that HELLP syndrome:

a. is a mild form of preeclampsia.
b. can be diagnosed by a nurse alert to its symptoms.
c. is characterized by hemolysis, elevated liver enzymes, and low platelets.
d. is associated with preterm labor but not perinatal mortality.

Answer 46

ANS CThe acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased, and so is perinatal mortality.

Question 47

Nurses should be aware that chronic hypertension:
a. is defined as hypertension that begins during pregnancy and lasts for the duration
of pregnancy.
b. is considered severe when the systolic blood pressure (BP) is greater than 140 mm
Hg or the diastolic BP is greater than 90 mm Hg.
c. is general hypertension plus proteinuria.
d. can occur independently of or simultaneously with gestational hypertension.

Answer 47

ANS: D
Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks after birth. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.

Question 48

In planning care for women with preeclampsia, nurses should be aware that:

a. induction of labor is likely, as near term as possible.
b. if at home, the woman should be confined to her bed, even with mild preeclampsia.
c. a special diet low in protein and salt should be initiated.
d. vaginal birth is still an option, even in severe cases.

Answer 48

ANS: A
Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.

Question 49

Magnesium sulfate is given to women with preeclampsia and eclampsia to:

a. improve patellar reflexes and increase respiratory efficiency.
b. shorten the duration of labor.
c. prevent and treat convulsions.
d. prevent a boggy uterus and lessen lochial flow.

Answer 49

ANS:CMagnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.

Question 50

A woman presents to the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?
a. Incomplete b. Inevitable c. Threatened d. Septic

Answer 50

ANS: C
A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would present with heavy bleeding, mild to severe cramping, and cervical dilation. An inevitable abortion manifests with the same symptoms as an incomplete abortion: heavy bleeding, mild to severe cramping, and cervical dilation. A woman with a septic abortion presents with malodorous bleeding and typically a dilated cervix

Question 51

The perinatal nurse is giving discharge instructions to a woman after suction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse would be:
a. “If you get pregnant within 1 year, the chance of a successful pregnancy is very
small. Therefore, if you desire a future pregnancy, it would be better for you to use
the most reliable method of contraception available.”
b. “The major risk to you after a molar pregnancy is a type of cancer that can be
diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult.”
c. “If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time.”
d. “Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.”

Answer 51

ANS:BThis is an accurate statement. Beta-human chorionic gonadotropin (hCG) levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a “zero” hCG level. If the woman were to become pregnant, it could obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device is acceptable.

Question 52

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:

a. bleeding.
b. intense abdominal pain.
c. uterine activity.
d. cramping

Answer 52

ANS: B
Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

Question 53

Methotrexate is recommended as part of the treatment plan for which obstetric complication?

a. Complete hydatidiform mole
b. Missed abortion
c. Unruptured ectopic pregnancy
d. Abruptio placentae

Answer 53

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

Question 54

A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure?

a. Amniocentesis for fetal lung maturity
b. Ultrasound for placental location
c. Contraction stress test (CST)
d. Internal fetal monitoring

Answer 54

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

Question 55

A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of:

a. placenta previa.
b. vasa previa.
c. severe abruptio placentae.
d. disseminated intravascular coagulation (DIC).

Answer 55

ANS: B
Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical
vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for
laceration at any time, but laceration occurs most frequently during ROM. The sudden
appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate
without other known risk factors should immediately alert the nurse to the possibility of vasa
previa. The presence of placenta previa most likely would be ascertained before labor and
would be considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a board-like uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors and causes widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric

Question 56

A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the woman’s umbilicus and recognizes this assessment finding as:

a. normal integumentary changes associated with pregnancy.
b. Turner’s sign associated with appendicitis.
c. Cullen’s sign associated with a ruptured ectopic pregnancy.
d. Chadwick’s sign associated with early pregnancy.

Answer 56

ANS:C
Cullen’s sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turner’s sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwick’s sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy.

Question 57

As related to the care of the patient with miscarriage, nurses should be aware that:
a. it is a natural pregnancy loss before labor begins.
b. it occurs in fewer than 5% of all clinically recognized pregnancies.
c. it often can be attributed to careless maternal behavior such as poor nutrition or
excessive exercise.
d. if it occurs before the 12th week of pregnancy, it may manifest only as moderate
discomfort and blood loss.

Answer 57

ANS: D
Before the sixth week the only evidence may be a heavy menstrual flow. After the 12th week more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but by definition it occurs before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriage can be caused by a number of disorders or illnesses outside of the mother’s control or knowledge

Question 58

Which condition would not be classified as a bleeding disorder in late pregnancy?

a. Placenta previa
b. Abruptio placentae
c. Spontaneous abortion
d. Cord insertion

Answer 58

ANS: C
Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Cord insertion is a cause of bleeding disorders in later pregnancy

Question 59

In providing nutritional counseling for the pregnant woman experiencing cholecystitis, the nurse would:

a. assess the woman’s dietary history for adequate calories and proteins.
b. instruct the woman that the bulk of calories should come from proteins.
c. instruct the woman to eat a low-fat diet and avoid fried foods.
d. instruct the woman to eat a low-cholesterol, low-salt diet.

Answer 59

ANS:C
Instructing the woman to eat a low-fat diet and avoid fried foods is appropriate nutritional counseling for this patient. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated

Question 60

Which maternal condition always necessitates delivery by cesarean section?

a. Partial abruptio placentae
b. Total placenta previa
c. Ectopic pregnancy
d. Eclampsia

Answer 60

ANS: B
In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred. If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted in cases of partial abruptio placentae. If the fetus has died, a vaginal delivery is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control.

Question 61

Spontaneous termination of a pregnancy is considered to be an abortion if:

a. the pregnancy is less than 20 weeks.
b. the fetus weighs less than 1000 g.
c. the products of conception are passed intact.
d. no evidence exists of intrauterine infection.

Answer 61

ANS: A
An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection.

Question 62

An abortion in which the fetus dies but is retained within the uterus is called a(n): a. inevitable abortion.

b. missed abortion.
c. incomplete abortion.
d. threatened abortion.

Answer 62

ANS: B
Missed abortion refers to retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation.

Question 63

A placenta previa in which the placental edge just reaches the internal os is more commonly known as:

a. total.
b. partial.
c. complete. d. marginal.

Answer 63

ANS: D
A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. When the patient experiences a partial placenta previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete placenta previa is termed total. The placenta completely covers the internal cervical os.

Question 64

Which condition indicates concealed hemorrhage when the patient experiences an abruptio placentae?

a. Decrease in abdominal pain
b. Bradycardia
c. Hard, board-like abdomen
d. Decrease in fundal heigh

Answer 64

ANS: C
Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, board-like abdomen. Abdominal pain may increase. The patient will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height will increase.

Question 65

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to:

a. assess fetal heart rate (FHR) and maternal vital signs.
b. perform a venipuncture for hemoglobin and hematocrit levels.
c. place clean disposable pads to collect any drainage.
d. monitor uterine contractions.

Answer 65

ANS: A
Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.

Question 66

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of:

a. anxiety due to hospitalization.
b. worsening disease and impending convulsion.
c. effects of magnesium sulfate.
d. gastrointestinal upset.

Answer 66

ANS: B
Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication.

Question 67

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

a. Bed rest
b. Ritodrine IV
c. NPO
d. Narcotic analgesia every 3 hours, prn

Answer 67

ANS: A NURSINGTB.COM
Decreasing the woman’s activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine IV is not the first drug of choice for tocolytic medications. There is no reason for having the woman placed NPO. At times dehydration may produce contractions, so hydration is important. Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions.

Question 68

A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that:

a. bed rest and analgesics are the recommended treatment.
b. she will be unable to conceive in the future.
c. a D&C will be performed to remove the products of conception.
d. hemorrhage is the major concern.

Answer 68

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

Question 69

Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion?

a. Chromosomal abnormalities
b. Infections
c. Endocrine imbalance
d. Immunologic factors

Answer 69

ANS: A
At least 50% of pregnancy losses result from chromosomal abnormalities that are incompatible with life. Maternal infection may be a cause of early miscarriage. Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss. Women who have repeated early pregnancy losses appear to have immunologic factors that play a role in spontaneous abortion incidents

Question 70

The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve:

a. corticosteroids to reduce inflammation.
b. IV therapy to correct fluid and electrolyte imbalances.
c. an antiemetic, such as pyridoxine, to control nausea and vomiting.
d. enteral nutrition to correct nutritional deficits.

Answer 70

ANS: B
Initially, the woman who is unableNUtoRkSeINepGTdBo.wCOnMclear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.

Question 71

A patient who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include: (Select all that apply.)

a. iron supplementation.
b. resumption of intercourse at 6 weeks following the procedure.
c. referral to a support group if necessary.
d. expectation of heavy bleeding for at least 2 weeks.
e. emphasizing the need for rest.

Answer 71

ANS:A,C,E
The woman should be advised to consume a diet high in iron and protein. For many women iron supplementation is also necessary. Acknowledge that the patient has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The patient should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her provider.

Question 72

The reported incidence of ectopic pregnancy in the United States has risen steadily over the past two decades. Causes include the increase in STDs accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for symptoms such as: (Select all that apply.)

a. pelvic pain.
b. abdominal pain.
c. unanticipated heavy bleeding.
d. vaginal spotting or light bleeding.
e. missed period.

Answer 72

ANS: A, B, D, E
A missed period or spotting can easily be mistaken by the patient as early signs of pregnancy.
More subtle signs depend on exactly where the implantation occurs. The nurse must be
thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the patient often exhibits severe pain accompanied by intra-abdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.

Question 73

In planning for home care of a woman with preterm labor, which concern must the nurse address?
a. Nursing assessments will be different from those done in the hospital setting.
b. Restricted activity and medications will be necessary to prevent recurrence of
preterm labor.
c. Prolonged bed rest may cause negative physiologic effects.
d. Home health care providers will be necessary.

Answer 73

ANS: C
Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged after birth recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many women will receive home health nurse visits, but care is individualized for each woman.

Question 74

The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?

a. Assessing deep tendon reflexes (DTRs)
b. Assessing for chest discomfort and palpitations
c. Assessing for bradycardia
d. Assessing for hypoglycemi

Answer 74

ANS: B
Terbutaline is a 2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. 2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.

Question 75

In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects?

a. Urine output of 160 mL in 4 hours
b. Deep tendon reflexes 2+ and no clonus
c. Respiratory rate of 16 breaths/min
d. Serum magnesium level of 10 mg/dL

Answer 75

ANS: D
The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.

Question 76

A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:
a. stimulate fetal surfactant production.
b. reduce maternal and fetal tachycardia associated with ritodrine administration.
c. suppress uterine contractions.
d. maintain adequate maternal respiratory effort and ventilation during magnesium
sulfate therapy.

Answer 76

ANS: A
Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.

Question 77

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing
preterm labor. What finding indicates that preterm labor is occurring?
a. Estriol is not found in maternal saliva.
b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
c. Fetal fibronectin is present in vaginal secretions.
d. The cervix is effacing and dilated to 2 cm.

Answer 77

ANS: D
Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes

Question 78

A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman’s labor?

a. She is exhibiting hypotonic uterine dysfunction.
b. She is experiencing a normal latent stage.
c. She is exhibiting hypertonic uterine dysfunction.
d. She is experiencing pelvic dystocia.

Answer 78

ANS: C
Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. The contraction pattern seen in this woman signifies hypertonic uterine activity. Typically uterine activity in this phase occurs at 4- to 5-minute intervals lasting 30 to 45 seconds. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.

Question 79

Which assessment is least likely to be associated with a breech presentation?

a. Meconium-stained amniotic fluid
b. Fetal heart tones heard at or above the maternal umbilicus
c. Preterm labor and birth
d. Postterm gestation

Answer 79

ANS: D
Postterm gestation is not likely to be seen with a breech presentation. The presence of
meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.

Question 80

A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?

a. Prolonged latent phase
b. Protracted active phase
c. Arrest of active phase
d. Protracted descent

Answer 80

ANS: C
With an arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor

Question 81

In evaluating the effectiveness of oxytocin induction, the nurse would expect:

a. contractions lasting 80 to 90 seconds, 2 to 3 minutes apart.
b. the intensity of contractions to be at least 110 to 130 mm Hg.
c. labor to progress at least 2 cm/hr dilation.
d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.

Answer 81

ANS: A
The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 80 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min.

Question 82

A pregnant woman’s amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority?

a. Placing the woman in the knee-chest position.
b. Covering the cord in sterile gauze soaked in saline.
c. Preparing the woman for a cesarean birth.
d. Starting oxygen by face mask.

Answer 82

ANS: A
The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.

Question 83

Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to:

a. enhance uteroplacental perfusion in an aging placenta.
b. increase amniotic fluid volume.
c. ripen the cervix in preparation for labor induction.
d. stimulate the amniotic membranes to rupture.

Answer 83

ANS: C
It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. It is not administered to enhance uteroplacental perfusion in an aging placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.

Question 84

The nurse, caring for a patient whose labor is being augmented with oxytocin, recognizes that the oxytocin should be discontinued immediately if there is evidence of:

a. uterine contractions occurring every 8 to 10 minutes.
b. a fetal heart rate (FHR) of 180 with absence of variability.
c. the patient’s needing to void.
d. rupture of the patient’s amniotic membranes.

Answer 84

ANS: B
This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation. The patient’s needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the patient experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the patient’s membranes have ruptured.

Question 85

With regard to the care management of preterm labor, nurses should be aware that:
a. all women must be considered at risk for preterm labor and prediction is so
hit-and-miss, teaching pregnant women the symptoms probably causes more harm
through false alarms.
b. Braxton Hicks contractions often signal the onset of preterm labor.
c. preterm labor is likely to be the start of an extended labor, a woman with
symptoms can wait several hours before contacting the primary caregiver.
d. the diagnosis of preterm labor is based on gestational age, uterine activity, andprogressive cervical change.

Answer 85

ANS: D
Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor.

Question 86

As relates to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
a. the drugs can be given efficaciously up to the designated beginning of term at 37 weeks.
b. there are no important maternal (as opposed to fetal) contraindications.
c. its most important function is to afford the opportunity to administer antenatal
glucocorticoids.
d. if the patient develops pulmonary edema while receiving tocolytics, intravenous
(IV) fluids should be given.

Answer 86

ANS: C
Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the
best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic
therapy outweigh the benefits. There are important maternal contraindications to tocolytic
therapy. Tocolytic-induced edema can be caused by IV fluids

Question 87

With regard to dysfunctional labor, nurses should be aware that:
a. women who are underweight are more at risk.
b. women experiencing precipitous labor are about the only “dysfunctionals” not to
be exhausted.
c. hypertonic uterine dysfunction is more common than hypotonic dysfunction.
d. abnormal labor patterns are most common in older women.

Answer 87

ANS: B
Precipitous labor lasts less than 3 hours. Short women more than 30 lbs overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women less than 20 years of age.

Question 88

The least common cause of long, difficult, or abnormal labor (dystocia) is:

a. midplane contracture of the pelvis.
b. compromised bearing-down efforts as a result of pain medication.
c. disproportion of the pelvis.
d. low-lying placenta.

Answer 88

ANS: C

The least common cause of dystocia is disproportion of the pelvis.

Question 89

Nurses should be aware that the induction of labor:

a. can be achieved by external and internal version techniques.
b. is also known as a trial of labor (TOL).
c. is almost always done for medical reasons.
d. is rated for viability by a Bishop score.

Answer 89

ANS: D
Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons.

Question 90

While caring for the patient who requires an induction of labor, the nurse should be cognizant that:
a. ripening the cervix usually results in a decreased success rate for induction.
b. labor sometimes can be induced with balloon catheters or laminaria tents.
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c. oxytocin is less expensive than prostaglandins and more effective but creates greater health risks.
d. amniotomy can be used to make the cervix more favorable for labor.

Answer 90

ANS: B
Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe.

Question 91

With regard to the process of augmentation of labor, the nurse should be aware that it:
a. is part of the active management of labor that is instituted when the labor process
is unsatisfactory.
b. relies on more invasive methods when oxytocin and amniotomy have failed.
c. is a modern management term to cover up the negative connotations of
forceps-assisted birth.
d. uses vacuum cups.

Answer 91

ANS:A
Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation.

Question 92

The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births.

a. Viral
b. Periodontal
c. Cervical
d. Urinary tract

Answer 92

ANS: A
The infections that increase the risk of preterm labor and birth are all bacterial. They include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, it is important for the patient to participate in early, continual, and comprehensive prenatal care. Evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent infection. Cervical infections of a bacterial nature have been linked to preterm labor and birth. The presence of urinary tract infections increases the risk of preterm labor and birth.

Question 93

The standard of care for obstetrics dictates that an internal version may be used to manipulate the:

a. fetus from a breech to a cephalic presentation before labor begins.
b. fetus from a transverse lie to a longitudinal lie before cesarean birth.
c. second twin from an oblique lie to a transverse lie before labor begins.
d. second twin from a transverse lie to a breech presentation during vaginal birth.

Answer 93

ANS: D
Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated.

Question 94

The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is:

a. a gravida 3 who has had two low-segment transverse cesarean births.
b. a gravida 2 who had a low-segment vertical incision for delivery of a 10-lb infant.
c. a gravida 5 who had two vaginal births and two cesarean births.
d. a gravida 4 who has had all cesarean births.

Answer 94

ANS: D
The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine rupture.

Question 95

Before the physician performs an external version, the nurse should expect an order for a:

a. tocolytic drug.
b. contraction stress test (CST).
c. local anesthetic.
d. Foley catheter.

Answer 95

ANS: A
A tocolytic drug will relax the uterus before and during version, thus making manipulation easier. CST is used to determine the fetal response to stress. A local anesthetic is not used with external version. The bladder should be emptied; however, catheterization is not necessary.

Question 96

A maternal indication for the use of forceps is:

a. a wide pelvic outlet.
b. maternal exhaustion.
c. a history of rapid deliveries.
d. failure to progress past 0 station

Answer 96

ANS: B
A mother who is exhausted may be unable to assist with the expulsion of the fetus.
The patient with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum extraction.

Question 97

The priority nursing intervention after an amniotomy should be to:

a. assess the color of the amniotic fluid.
b. change the patient’s gown.
c. estimate the amount of amniotic fluid.
d. assess the fetal heart rate.

Answer 97

ANS: D
The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Secondary to FHR assessment, amniotic fluid amount, color, odor, and consistency is assessed. Dry clothing is important for patient comfort; however, it is not the top priority.

Question 98

The priority nursing care associated with an oxytocin (Pitocin) infusion is:

a. measuring urinary output.
b. increasing infusion rate every 30 minutes.
c. monitoring uterine response.
d. evaluating cervical dilation.

Answer 98

ANS: C
Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse’s priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of Pitocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labor progression is the standard of care for all labor patients.

Question 99

Immediately after the forceps-assisted birth of an infant, the nurse should:

a. assess the infant for signs of trauma.
b. give the infant prophylactic antibiotics.
c. apply a cold pack to the infant’s scalp.
d. measure the circumference of the infant’s head.

Answer 99

ANS: A
The infant should be assessed for NbrUuRisSiInNgGoTrBa.CbOraMsions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would put the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment.

Question 100

Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction?

a. Amniotomy
b. Intravenous Pitocin
c. Transcervical catheter
d. Vaginal insertion of prostaglandins

Answer 100

ANS: C
Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction. Other methods to expand and gradually dilate the cervix include hydroscopic dilators such as laminaria tents (made from desiccated seaweed), or Lamicel (contains magnesium sulfate). Amniotomy is a surgical method of augmentation and induction. Intravenous Pitocin and insertion of prostaglandins are medical methods of induction.

Question 101

Complications and risks associated with cesarean births include: (Select all that apply.)

a. placental abruption.
b. wound dehiscence.
c. hemorrhage.
d. urinary tract infections.
e. fetal injuries.

Answer 101

ANS: B, C, D, E
Placental abruption and placenta previa are both indications for cesarean birth and are not complications thereof. Wound dehiscence, hemorrhage, urinary tract infection, and fetal injuries are all possible complications and risks associated with delivery by cesarean section.

Question 102

Induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse in the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. These include: (Select all that apply.)

a. rupture of membranes at or near term.
b. convenience of the woman or her physician.
c. chorioamnionitis (inflammation of the amniotic sac).
d. postterm pregnancy.
e. fetal death.

Answer 102

ANS: A, C, D, E
These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks’ completed gestation