Week 2 EAQ/HESIs

Question 1

You also review Susan’s lab work, recalling that pregnancy tests on urine or blood are determined to be positive based on the presence of a particular hormone. This biologic marker of pregnancy is:

human chorionic gonadotropin

estrogen

progesterone

follicle-stimulating hormone

Answer 1

human chorionic gonadotropin

Human chorionic gonadotropin (HCG), produced by the trophoblast cells of the placenta soon after implantation of a fertilized ovum, is a biologic marker of pregnancy. It can be detected in maternal serum and urine as early as six days after conception, depending on the test performed. It reaches its maximum level in 50-70 days. The presence of HCG in Susan’s blood is considered a probable sign of pregnancy. Positive pregnancy tests can also occur if the client has certain tumors which produce HCG. Progesterone is not a biological marker of pregnancy, but increases in progesterone levels are critical for the maintenance of a pregnancy.

Question 2

During Susan’s pelvic examination, a bluish discoloration of the cervix and vaginal mucosa is observed. This is a sign of pregnancy and is documented as :

Answer 2

Chadwicks Sign

Question 3

Susan has noticed some darkening of her face in the shape of a “mask.” You advise her that this is normal and record it as:

Answer 3

Chloasma

Question 4

During pregnancy, women are more prone to develop vaginal yeast infections due to a/an
_________ in vaginal pH.

Answer 4

increase

Question 4

Susan inquires, “Is this what my mother calls “the baby dropping?” You acknowledge her mother’s information, and tell Susan that this event is called:

Answer 4

lightening

Question 5

You explain that the contractions she describes are common during late pregnancy and function to increase blood flow to the uterus. They are referred to as ____________ contractions.

Answer 5

braxton hicks

Question 6

Morning sickness generally disappears by the end of which month?

Fifth month

Third month

Fourth month

Second month

Answer 6

Third month

Question 7

Which descriptor would the nurse use when explaining to a client how to time the frequency of contractions?

From the end of 1 contraction to the end of the next contraction

From the end of 1 contraction to the beginning of the next contraction

From the beginning of 1 contraction to the end of the next contraction

From the beginning of 1 contraction to the beginning of the next contraction
Confident

Answer 7

From the beginning of 1 contraction to the beginning of the next contraction

Question 8

Which technique would the nurse suggest to a laboring woman’s partner that involves gently stroking the woman’s abdomen in rhythm with her breathing during a contraction?

Massage

Effleurage

Acupressure

Counterpressure

Answer 8

Effleurage

Question 9

At which point during a human pregnancy does the embryo become a fetus?

During the 8th week of the pregnancy

At the end of the 2nd week of pregnancy

When the fertilized egg becomes implanted

When the products of conception are seen on the ultrasound

Answer 9

During the 8th week of the pregnancy

Question 10

When a client at 39 weeks’ gestation arrives at the birthing suite she says, “I’ve been having contractions for 3 hours, and I think my water broke.” Which action would the nurse take to confirm that the membranes have ruptured?

Take the client’s oral temperature.

Test the leaking fluid with nitrazine paper.

Obtain a clean-catch urine specimen.

Inspect the perineum for leaking fluid.

Answer 10

Test the leaking fluid with nitrazine paper.

Question 11

A prenatal client’s vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client’s clinical record?

Hegar

Goodell

Chadwick

Braxton-Hicks

Answer 11

Chadwick

Question 12

Applying ______ packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation.

Answer 12

warm

Question 13

Progressive cervical _________ is the most accurate indication of true labor

Answer 13

dilation

Question 14

When can a primigravida fetal heartbeat be heard for the first time?

A stethoscope at 4 weeks

A fetoscope at 10 to 12 weeks

Doppler ultrasound after 20 weeks

Doppler ultrasound at 10 to 12 weeks

Answer 14

Doppler ultrasound at 10 to 12 weeks

Question 15

Which condition is detected by an alpha-fetoprotein test?

Kidney defects

Cardiac anomalies

Neural tube defects

Urinary tract anomalies

Answer 15

Neural tube defects

Question 16

Cigarette smoking or continued exposure to secondary smoke causes both maternal and fetal ______________, resulting in fetal growth retardation and increased fetal and infant mortality.

Answer 16

vasoconstriction

Question 17

The amniotic fluid provides __________ , not nutrition

Answer 17

protection

Question 18

The most highly sensitive time within the developing human embryo for malformation caused by environmental teratogens is ___________ at 8 weeks’ gestation.

Answer 18

cleft palate

Question 19

Which would the nurse ask the postpartum client to do before assessing her uterine fundus?

Drink fluids.

Empty her bladder.

Perform the Valsalva maneuver.

Assume the semi-Fowler position.

Answer 19

Empty her bladder.

Question 20

The fetus of a client in labor is found to be at +1 station. Where would the nurse locate the presenting part?

On the perineum

High in the pelvis

Just below the ischial spines

Slightly above the ischial spines

Answer 20

Just below the ischial spines

Question 21

Which statement explains the primary purpose of the side-lying position during labor?

“Lying on the side prevents fetal hyperactivity.”

“It makes it less likely that you’ll have nausea and vomiting.”

“Lying on the side encourages the presenting part to descend.”

“It enhances blood flow to the uterus and makes contractions easier

Answer 21

“It enhances blood flow to the uterus and makes contractions easier

Question 22

Where is the presenting part of the fetus when station is -1?

1 cm above the ischial spines

1 cm below the ischial spines

Visible at the vaginal opening

At the level of the ischial spines

Answer 22

1 cm above the ischial spines

Question 23

Which prenatal test provides the earliest diagnosis of fetal defects?

Nonstress test

Amniocentesis

Chorionic villus sampling

Percutaneous umbilical blood sampling

Answer 23

Chorionic villus sampling

Question 24

Increased _______ production during pregnancy causes hyperplasia of the vaginal mucosa, which leads to increased production of mucus by the endocervical glands.

Answer 24

estrogen

Question 25

The _______ volume increases by approximately 50% during pregnancy.

Answer 25

blood

Question 26

Which complication would the nurse anticipate when a client who is 36 weeks’ pregnant presents with swelling of the face, blurred vision, and epigastric discomfort?

Preeclampsia

Placenta previa

Gestational diabetes

Hyperemesis gravidarum

Answer 26

Preeclampsia

Question 27

A patient is admitted to the labor and delivery unit. The fetal monitor is applied, and the patient moves into a supine position for the assessment. During the examination, the nurse notes that the FHR is 124 beats per minute with moderate variability and that the patient’s fundus is soft on palpation. Vital signs are blood pressure of 86/40, pulse of 96 beats per minute, respiratory rate of 20 breaths per minute, and temperature of 36.8°C (98.2°F). What should the nurse do first?

A. Notify the practitioner of an abnormal finding.
B. Reposition the patient so that the patient is not supine.
C. Repeat the blood pressure reading.
D. Ask if the patient has had problems with low blood pressure in the past.

Answer 27

B. Reposition the patient so that the patient is not supine.

Question 28

A patient delivered the first child 3 years ago. A year later the patient had a spontaneous abortion at 12 weeks’ gestation. The patient presents to the antepartum unit at 38 weeks’ gestation reporting rupture of membranes 1 hour ago, but the patient is not having contractions. What is the nurse’s calculation of the patient’s gravidity and parity?

A. Gravida 2, para 1
B. Gravida 2, para 2
C. Gravida 3, para 1
D. Gravida 3, para 2

Answer 28

C. Gravida 3, para 1

Question 29

A multigravida is being admitted for early labor at 40 weeks’ gestation. When asked about leaking fluid or having bloody show, the patient mentions having had a gush of fluid about 2 hours ago. Which important question should the nurse then ask the patient?

A. “Did you notice what color the fluid was?”
B. “Are you sure it wasn’t urine?”
C. “What time did your membranes rupture?”
D. “Did you happen to notice if the fluid had an odor?”

Answer 29

A. “Did you notice what color the fluid was?”

Question 30

A 32-year-old multipara at 39 weeks’ gestation is being admitted to the labor and delivery unit. While auscultating the lung and heart sounds, the nurse notices a thin, yellowish discharge from the patient’s right nipple. The patient also notices it and comments, “I don’t know what that is, but I have noticed it for the last couple of months.” What is the best way for the nurse to respond?

A. “I need to report that to the practitioner. You may have an infection.”
B. “It is most likely colostrum, indicating your breasts are getting ready for the baby.”
C. “I have seen that before, but I am not sure what causes it.”
D. “Have you ever had a mammogram to check for breast cancer?”

Answer 30

B. “It is most likely colostrum, indicating your breasts are getting ready for the baby.”

Question 31

During the labor admission assessment, the nurse asks whether the patient has used alcohol, substances, or herbal preparations. The patient glances at family members and then quickly denies using anything. The patient then becomes quiet, responding to the nurse’s questions with short answers and begins to appear tense. What does this behavior tell the nurse?

A. Sensitive questions should be asked again when the patient is alone.
B. The patient is probably ashamed of lying to the nurse about using drugs.
C. The family will probably give the nurse more truthful answers.
D. The prenatal record should have the information, and the nurse does not need to follow up further with the patient.

Answer 31

A. Sensitive questions should be asked again when the patient is alone.

Question 32

Which risk factors are associated with excessive weight gain in pregnancy?

A. Preeclampsia, gestational diabetes, cesarean birth, macrosomia, and LGA infants
B. Preeclampsia, gestational diabetes, cesarean birth, babies that are small for gestational age
C. Gestational diabetes, cesarean birth, stillbirth, preeclampsia, and low birth weight
D. Gestational diabetes, cesarean birth, stillbirth, preeclampsia, and preterm birth

Answer 32

A. Preeclampsia, gestational diabetes, cesarean birth, macrosomia, and LGA infants

Question 33

While performing the initial assessment of a multipara who is in labor at 41 weeks’ gestation, the nurse notices mild edema of the lower extremities. The patient is concerned about the swelling of the feet. What should the nurse tell the patient about the edema in the lower extremities?

A. Mild edema may indicate poor circulation.
B. Mild edema of the lower extremities may indicate preeclampsia.
C. Mild edema of the lower extremities is common in pregnancy.
D. Mild edema of the lower extremities is uncommon in pregnancy.

Answer 33

C. Mild edema of the lower extremities is common in pregnancy.

Question 34

The postpartum nurse has just received report on a new patient who had a cesarean delivery 2 hours earlier. The nurse performs an initial postpartum assessment and then a fundal assessment, which reveals that the uterus is boggy and 3 cm above the umbilicus and midline. Which nursing response is appropriate?

A. Perform fundal massage until the fundus is firm.
B. Avoid fundal massage because the patient underwent a cesarean delivery.
C. Notify the practitioner that the uterus is boggy.
D. Add an additional 10 units of oxytocin to the IV fluids already infusing.

Answer 34

A. Perform fundal massage until the fundus is firm.

Question 35

The nurse is assessing a patient during the immediate postpartum period following a vaginal delivery and finds that the uterus is boggy and displaced to the right. Which action should the nurse perform?

A. Initiate fundal massage and monitoring the patient for uterine involution.
B. Encourage the patient to void or confirm orders for bladder catheterization if needed.
C. Assess lochia for excessive bleeding.
D. Notify the practitioner of possible retained placental fragments

Answer 35

B. Encourage the patient to void or confirm orders for bladder catheterization if needed.

Question 36

The nurse has completed a fundal assessment after a vaginal delivery. The patient’s uterus remains boggy at the umbilicus and midline despite voiding and emptying the bladder. What should the nurse do?

A. Massage the uterus until the vaginal bleeding stops.
B. Perform fundal massage, cupping one hand over the fundus and supporting the uterus above the symphysis pubis with the other hand.
C. Call the practitioner because the patient is exhibiting uterine atony.
D. Massage the uterus as forcefully as the patient can tolerate.

Answer 36

B. Perform fundal massage, cupping one hand over the fundus and supporting the uterus above the symphysis pubis with the other hand.

Question 37

What is the most common cause of postpartum hemorrhage?

A. Uterine inversion
B. Uterine atony
C. Cervical lacerations
D. Coagulation defects

Answer 37

B. Uterine atony

Question 38

The nurse assesses the fundus of a multipara who delivered a full-term newborn 3 hours ago. The nurse finds the uterus to be boggy on palpation. The nurse massages the patient’s uterus and attempts to express any clots; however, bleeding is minimal, and no clots are expressed. The nurse also determines that the patient’s bladder is empty. What should be the nurse’s next course of action?

A. Assess the patient’s perineum for lacerations.
B. Nothing because the patient has minimal bleeding.
C. Assess the patient’s vital signs and notify the practitioner.
D. Administer a mainline IV bolus of 0.9% sodium chloride solution.

Answer 38

C. Assess the patient’s vital signs and notify the practitioner.

Question 39

A primigravida has just delivered at term, and the nurse is palpating the fundus. Where should the nurse expect to find the patient’s fundus?

A. Midline between the umbilicus and the symphysis pubis
B. Midline above the umbilicus
C. Deviated to the right between the umbilicus and the symphysis pubis
D. At the level of the umbilicus

Answer 39

A. Midline between the umbilicus and the symphysis pubis

Question 40

The nurse is assessing the fundus of a patient who delivered vaginally 2 days ago. How is the height of the fundus described in relation to the umbilicus?

A. The height of the uterine fundus is described in inches in relation to the umbilicus.
B. The height of the uterine fundus is described in centimeters in relation to the umbilicus.
C. The height of the uterine fundus is described in the number of fingers in relation to the umbilicus.
D. The height of the uterine fundus is described in millimeters in relation to the umbilicus.

Answer 40

B. The height of the uterine fundus is described in centimeters in relation to the umbilicus.