Maternal Newborn Nursing The Critical Components Of Nursing Care 2nd Edition by Roberta Durham – Test Bank
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Sample Test
Chapter 3: Genetics, Conception, Fetal Development, and
Reproductive Technology
Multiple Choice
1. The
color of a person’s hair is an example of which of the following?a. Genomeb.
Sex-link inheritancec. Genotyped. Phenotype
ANS: d
|
|
Feedback |
|
a. |
Genome is an organism’s
complete set of DNA. |
|
b. |
Sex-link inheritance refers
to genes or traits that are located only on the X chromosome. |
|
c. |
Genotype refers to a
person’s genetic makeup. |
|
d. |
Correct. Phenotype refers
to how genes are outwardly expressed, such as eye color, hair color, and
height. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Easy
2. Which
of the following statements by a pregnant woman indicates she needs additional
teaching on ways to reduce risks to her unborn child from the potential effects
of exposure to toxoplasmosis?a. “I will avoid rare lamb.”b. “I will wear a mask
when cleaning my cat’s litter box.”c. “I understand that exposure to
toxoplasmosis can cause blindness in the baby.”d. “I will avoid rare beef.”
ANS: b
|
|
Feedback |
|
a. |
Exposure occurs when the
protozoan parasite found in cat feces and uncooked or rare beef and lamb is
ingested. |
|
b. |
Correct. Pregnant women and
women who are attempting pregnancy should avoid contact with cat feces.
Exposure occurs when the protozoan parasite found in cat feces and uncooked
or rare beef and lamb is ingested. Wearing a mask will not decrease the risk
through ingestion of the parasite. |
|
c. |
Exposure to toxoplasmosis
can cause fetal death, mental retardation, and blindness. |
|
d. |
Exposure occurs when the
protozoan parasite found in cat feces and uncooked or rare beef and lamb is
ingested. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Application | Content Area: Maternity | Client Need: Health Promotion
and Maintenance | Difficulty Level: Moderate
3. The
fetal circulatory structure that connects the pulmonary artery with the
descending aorta is known as which of the following?a. Ductus venosusb. Foramen
ovalec. Ductus arteriosusd. Internal iliac artery
ANS: c
|
|
Feedback |
|
a. |
The ductus venosus connects
the umbilical vein to the inferior vena cava. |
|
b. |
The foramen ovale is the opening
between the right and left atria. |
|
c. |
Correct. |
|
d. |
The internal iliac artery
connects the external iliac artery to the umbilical artery. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Adaptation | Difficulty Level: Easy
4. A
woman at 40 weeks’ gestation has a diagnosis of oligohydramnios. Which of the
following statements related to oligohydramnios is correct?a. It indicates that
there is a 25% increase in amniotic fluid.b. It indicates that there is a 25%
reduction of amniotic fluid.c. It indicates that there is a 50% increase in
amniotic fluid.d. It indicates that there is a 50% reduction of amniotic fluid.
ANS: d
|
|
Feedback |
|
a. |
Oligohydramnios is a decrease,
not an increase in amniotic fluid. |
|
b. |
Oligohydramnios is a 50%
reduction in amniotic fluid. |
|
c. |
Oligohydramnios is a
decrease, not an increase in amniotic fluid. |
|
d. |
Correct. Oligohydramnios
refers to a decreased amount of amniotic fluid of less than 500 mL at term or
50% reduction of normal amounts. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Application | Content Area: Maternity | Client Need: Reduction of Risk
Potential | Difficulty Level: Moderate
5. A
diagnostic test commonly used to assess problems of the fallopian tubes is:a.
Endometrial biopsyb. Ovarian reserve testingc. Hysterosalpingogramd. Screening
for sexually transmitted infections
ANS: c
|
|
Feedback |
|
a. |
Endometrial biopsy provides
information on the response of the uterus to hormonal signals. |
|
b. |
Ovarian reserve testing is
used to assess ovulatory functioning. |
|
c. |
Correct.
Hysterosalpingogram provides information on the endocervical canal, uterine
cavity, and fallopian tubes. |
|
d. |
STIs can cause adhesions
within the fallopian tubes, but screening cannot confirm that adhesions are
present. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective
Care Environment | Difficulty Level: Moderate
6. The
nurse is interviewing a gravid woman during the first prenatal visit. The woman
confides to the nurse that she lives with a number of pets. The nurse should
advise the woman to be especially careful to refrain from coming in contact
with the stool of which of the pets?
7. Cat
8. Dog
9. Hamster
10. Bird
ANS: a
|
|
Feedback |
|
a. |
The patient should refrain
from coming in direct contact with cat feces. Cats often harbor
toxoplasmosis, a teratogenic illness. |
|
b. |
No pathology has been associated
with the feces of pet dogs. |
|
c. |
No pathology has been
associated with the feces of pet hamsters. |
|
d. |
No pathology has been
associated with the feces of pet birds. |
KEY: Integrated Process: Nursing Process: Implementation;
Teaching and Learning | Cognitive Level: Application | Content Area: Antepartum
Care; Disease Prevention | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
7. A
client is to take Clomiphene Citrate for infertility. Which of the following is
the expected action of this medication?
8. Decrease
the symptoms of endometriosis
9. Increase
serum progesterone levels
10. Stimulate
release of FSH and LH
11. Reduce
the acidity of vaginal secretions
ANS: c
|
|
Feedback |
|
a. |
Clomiphene Citrate will not
reduce a client’s symptoms of endometriosis. |
|
b. |
Clomiphene Citrate will not
increase a client’s progesterone levels. |
|
c. |
Clomiphene Citrate
stimulates release of FSH and LH. |
|
d. |
Clomiphene Citrate will not
reduce the acidity of vaginal secretions. |
KEY: Integrated Process: Nursing Process: Evaluation | Cognitive
Level: Comprehension | Content Area: Pharmacological and Parenteral Therapies:
Expected Effects/Outcomes | Client Need: Physiological Integrity:
Pharmacological and Parenteral Therapies | Difficulty Level: Moderate
8. The
nurse takes the history of a client, G2 P1, at her first prenatal visit. The
client is referred to a genetic counselor, due to her previous child having a
diagnosis of __________.
9. Unilateral
amblyopia
10. Subdural
hematoma
11. Sickle
cell anemia
12. Glomerular
nephritis
ANS: c
|
|
Feedback |
|
a. |
Amblyopia rarely results
from a genetic predisposition. |
|
b. |
A subdural hematoma does
not result from a genetic defect. |
|
c. |
Sickle cell anemia is an
autosomal recessive illness. This client needs to be seen by a genetic
counselor. |
|
d. |
Glomerular nephritis does
not result from a genetic defect. |
KEY: Integrated Process: Communication and Documentation;
Nursing Process: Assessment | Cognitive Level: Application | Content Area:
Antepartum Care; Collaboration with Interdisciplinary Team; Health History;
Referrals | Client Need: Health Promotion and Maintenance; Safe and Effective
Care Environment: Referrals | Difficulty Level: Moderate
9. A
nurse is teaching a woman about her menstrual cycle. The nurse states that
__________ is the most important change that happens during the secretory phase
of the menstrual cycle.
10. Maturation
of the graafian follicle
11. Multiplication
of the fimbriae
12. Secretion
of human chorionic gonadotropin
13. Proliferation
of the endometrium
ANS: d
|
|
Feedback |
|
a. |
The maturation of the
graafian follicle occurs during the follicular phase. |
|
b. |
There is no such thing as
the multiplication of the fimbriae. |
|
c. |
Human chorionic
gonadotropin is secreted by the fertilized ovum during the early weeks of a
pregnancy. |
|
d. |
The proliferation of the
endometrium occurs during the secretory phase of the menstrual cycle. |
KEY: Integrated Processes: Nursing Process: Implementation;
Teaching and Learning | Cognitive Level: Knowledge | Content Area: Health and
Wellness | Client Need: Health Promotion and Maintenance | Difficulty Level:
Difficult
10. An
ultrasound of a fetus’ heart shows that “normal fetal circulation is
occurring.” Which of the following statements is consistent with the finding?
11. A
right to left shunt is seen between the atria.
12. Blood
is returning to the placenta via the umbilical vein.
13. Blood
is returning to the right atrium from the pulmonary system.
14. A
right to left shunt is seen between the umbilical arteries.
ANS: a
|
|
Feedback |
|
a. |
This is correct. The
foramen ovale is a duct between the atria. In fetal circulation, there is a
right to left shunt through the duct. |
|
b. |
Blood returns to the
placenta via the umbilical arteries. |
|
c. |
Most of the blood bypasses
the pulmonary system. The blood that does enter the pulmonary system returns
to the left atrium. |
|
d. |
There is no duct between
the umbilical arteries. |
KEY: Integrated Process: Nursing Process: Analysis | Cognitive
Level: Comprehension | Content Area: Antepartum Care | Client Need: Health
Promotion and Maintenance | Difficulty Level: Difficult
11. The
clinic nurse knows that the part of the endometrial cycle occurring from
ovulation to just prior to menses is known as the:
12. Menstrual
phase
13. Proliferative
phase
14. Secretory
phase
15. Ischemic
phase
ANS: c
|
|
Feedback |
|
a. |
The menstrual phase is the
time of vaginal bleeding, approximately days 1 to 6. |
|
b. |
The proliferative phase
ends the menses through ovulation, approximately days 7 to 14. |
|
c. |
The secretory phases occurs
from the time of ovulation to the period just prior to menses, or
approximately days 15 to 26. |
|
d. |
The ischemic phase occurs
from the end of the secretory phase to the onset of menstruation, approximately
days 27 to 28. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need:
Health Promotion and Maintenance | Difficulty Level: Easy
12. A
clinic nurse explains to the pregnant woman that the amount of amniotic fluid
present at 24 weeks’ gestation is approximately:
13. 500
mL
14. 750
mL
15. 800
mL
16. 1000
mL
ANS: c
Amniotic fluid first appears at about 3 weeks. There are
approximately 30 mL of amniotic fluid present at 10 weeks’ gestation, and this
amount increases to approximately 800 mL at 24 weeks’ gestation. After that
time, the total fluid volume remains fairly stable until it begins to decrease
slightly as the pregnancy reaches term.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective
Care Environment | Difficulty Level: Easy
13. Information
provided by the nurse that addresses the function of the amniotic fluid is that
the amniotic fluid helps the fetus to maintain a normal body temperature and
also:
14. Facilitates
asymmetrical growth of the fetal limbs
15. Cushions
the fetus from mechanical injury
16. Promotes
development of muscle tone
17. Promotes
adherence of fetal lung tissue
ANS: b
|
|
Feedback |
|
a. |
Amniotic fluid allows for
symmetrical fetal growth. |
|
b. |
Amniotic fluid cushions the
fetus from mechanical injury. |
|
c. |
Amniotic fluid does not
promote muscle tone. |
|
d. |
Amniotic fluid prevents
adherence of the amnion to the fetus. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Comprehension | Content Area: Maternity | Client Need: Safe and
Effective Care Environment | Difficulty Level: Moderate
14. During
preconception counseling, the clinic nurse explains that the time period when
the fetus is most vulnerable to the effects of teratogens occurs from:
15. 2 to
8 weeks
16. 4
to12 weeks
17. 5 to
10 weeks
18. 6 to
15 weeks
ANS: a
The period of organogenesis lasts from approximately the second
until the eighth week of gestation during which time the embryo undergoes rapid
growth and differentiation. During organogenesis, the embryo is extremely
vulnerable to teratogens such as medications, alcohol, tobacco, caffeine,
illegal drugs, radiation, heavy metals, and maternal (TORCH) infections.
Structural fetal defects are most likely to occur during this period because
exposure to teratogens either before or during a critical period of development
of an organ can cause a malformation.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Integrity | Difficulty Level: Easy
15. A
major fetal development characteristic at 16 weeks’ gestation is:
16. The
average fetal weight is 450 grams
17. Lanugo
covers entire body
18. Brown
fat begins to develop
19. Teeth
begin to form
ANS: d
|
|
Feedback |
|
a. |
The average fetal weight at
16 weeks is 200 grams. |
|
b. |
Lanugo is present on the
head. |
|
c. |
Brown fat begins to develop
at 20 weeks. |
|
d. |
This is the correct answer. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Integrity | Difficulty Level: Moderate
16. Karen,
a 26-year-old woman, has come for preconception counseling and asks about caring
for her cat as she has heard that she “should not touch the cat during
pregnancy.” The clinic nurse’s best response is:
17. It is
best if someone other than you changes the cat’s litter pan during pregnancy so
that you have no risk of toxoplasmosis during pregnancy.
18. It is
important to have someone else change the litter pan during pregnancy and also
avoid consuming raw vegetables.
19. Have
you had any “flu-like” symptoms since you got your cat? If so, you may have
already had toxoplasmosis and there is nothing to worry about.
20. Toxoplasmosis
is a concern during pregnancy, so it is important to have someone else change
the cat’s litter pan and also to avoid consuming uncooked meat.
ANS: d
|
|
Feedback |
|
a. |
The nurse should also
explain that the patient should not eat uncooked meat as it is a potential
source for toxoplasmosis. |
|
b. |
Raw vegetables are not a
source for toxoplasmosis. |
|
c. |
This is not an accurate way
to diagnose if the woman has had toxoplasmosis. |
|
d. |
Women need to be aware
that Toxoplasma
gondii, a single-celled parasite, is responsible for the
infection toxoplasmosis. The majority of individuals who become infected with
toxoplasmosis are asymptomatic, although when present, symptoms are described
as “flu like” and include glandular pain and enlargement and myalgia. Severe
toxoplasmosis infection may cause damage to the fetal brain, eyes, or other
organs. Toxoplasmosis is usually acquired by consuming raw or poorly cooked
meat that has been contaminated with T.
gondii. Toxoplasmosis may also be acquired through close contact
with feces from an infected animal (usually cats) or soil that has been
contaminated with T.
gondii. |
KEY: Integrated Processes: Caring | Cognitive Level: Application
| Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
17. A
couple who has sought infertility counseling has been told that the man’s sperm
count is very low. The nurse advises the couple that spermatogenesis is
impaired when which of the following occur?
18. The testes
are overheated.
19. The
vas deferens is ligated.
20. The
prostate gland is enlarged.
21. The
flagella are segmented.
ANS: a
|
|
Feedback |
|
a. |
Spermatogenesis occurs in
the testes. High temperatures harm the development of the sperm. |
|
b. |
When the vas deferens is
ligated, a man has had a vasectomy and is sterile. The sterility is not due
to impaired spermatogenesis, but rather to the inability of the sperm to
migrate to the woman’s reproductive track. |
|
c. |
The enlarged prostrate has
no effect on spermatogenesis. |
|
d. |
The flagella are the
“tails” of the sperm. They are normally divided into the middle segment and
an end segment. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Easy
18. A
nurse working with an infertile couple has made the following nursing
diagnosis: Sexual dysfunction related to decreased libido. Which of the
following assessments is the likely reason for this diagnosis?
19. The
couple has established a set schedule for their sexual encounters.
20. The
couple has been married for more than 8 years.
21. The
couple lives with one set of parents.
22. The
couple has close friends who gave birth within the last year.
ANS: a
|
|
Feedback |
|
a. |
Couples who “schedule”
intercourse often complain that their sexual relationship is unsatisfying. |
|
b. |
Years of marriage are not
directly related to a couple’s sexual relationship. |
|
c. |
The fact that the couple
lives with one set of parents is unlikely related to their sexual
relationship. |
|
d. |
Although it can be very
difficult to be around couples who have become pregnant or have healthy
babies, this factor is not usually related to a couple’s sexual relationship. |
KEY: Integrated Process: Critical Thinking | Cognitive Level:
Knowledge | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
True/False
19. The
perinatal nurse explains to the student nurse that in the fetal circulation,
the lowest level of oxygen concentration is found in the umbilical arteries.
ANS: True
The highest oxygen concentration (PO2 =
30–35 mm Hg) is found in the blood returning from the placenta via the
umbilical vein; the lowest oxygen concentration occurs in blood shunted to the
placenta where reoxygenation takes place. The blood with the highest oxygen
content is delivered to the fetal heart, head, neck, and upper limbs, and the
blood with the lowest oxygen content is shunted toward the placenta.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Easy
Fill-in-the-Blank
20. After
birth, the perinatal nurse explains to the new mother that __________ is the
hormone responsible for stimulating milk production.
ANS: prolactin
Following birth and delivery of the placenta, there is an abrupt
decrease in estrogen. This event triggers an increased secretion of prolactin
(the hormone that stimulates milk production) by the anterior pituitary gland.
The posterior pituitary and hypothalamus play a role in the production and
secretion of oxytocin, a hormone that causes release of milk from the alveoli.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Easy
21. During
prenatal class, the childbirth educator describes the two membranes that
envelop the fetus. The __________ contains the amniotic fluid, and the
__________ is the thick, outer membrane.
ANS: amnion; chorion
The embryonic membranes (chorion and amnion) are early
protective structures that begin to form at the time of implantation. The thick
chorion, or outer membrane, forms first. It develops from the trophoblast and
encloses the amnion, embryo, and yolk sac. The amnion arises from the ectoderm
during early embryonic development. The amnion is a thin, protective structure
that contains the amniotic fluid. With embryonic growth, the amnion expands and
comes into contact with the chorion. The two fetal membranes are slightly
adherent and form the amniotic sac.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective
Care Environment | Difficulty Level: Easy
22. The
perinatal nurse is teaching nursing students about fetal circulation and
explains that fetal blood flows through the superior vena cava into the right
__________ via the __________.
ANS: atrium; foramen ovale
Blood flows through the vein from the placenta to the fetus.
Most of the blood bypasses the liver and then enters the inferior vena cava by
way of the ductus venosus, a vascular channel that connects the umbilical vein
to the inferior vena cava. The blood then empties into the right atrium, passes
through the foramen ovale (an opening in the septum between the right and left
atrium) into the left atrium, and then moves into the right ventricle and on
into the aorta. From the aorta, blood travels to the head, upper extremities,
and lower extremities.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective
Care Environment | Difficulty Level: Moderate
23. The
perinatal nurse explains to the student nurse that the growing embryo is called
a __________ beginning at 8 weeks of gestational age.
ANS: fetus
Major organs are being formed (organogenesis) during the first
weeks following fertilization. During this time, the developing organism is
called an embryo. By the end of 8 weeks, the embryo has sufficiently developed
to be called a fetus.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective
Care Environment | Difficulty Level: Easy
24. The
perinatal nurse defines a __________ as any substance that adversely affects
the growth and development of the embryo/fetus.
ANS: teratogen
Teratogens (drugs, radiation, and infectious agents that can
cause development of abnormal structures in an embryo) and a variety of
internal and external developmental events may cause structural and functional
defects.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Integrity | Difficulty Level: Easy
25. __________
__________ __________ is when sperm and oocytes are mixed outside the woman’s
body and then placed into the fallopian tube via laparoscopy.
ANS: Gamete intrafallopian transfer
Gamete intrafallopian transfer, also referred to as GIFT, is
used when there is a history of failed infertility treatment for anovulation,
or unexplained infertility, or low sperm count.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Integrity | Difficulty Level: Moderate
Multiple Response
26. A
woman seeks care at an infertility clinic. Which of the following tests may
this woman undergo to determine what, if any, infertility problem she may have?
(Select all that apply.)
27. Chorionic
villus sampling
28. Endometrial
biopsy
29. Hysterosalpingogram
30. Serum
FSH analysis
ANS. b, c, d
|
|
Feedback |
|
a. |
Chorionic villus sampling
is done to assess for genetic disorders of the fetus. |
|
b. |
Endometrial biopsy is
performed about 1 week following ovulation to detect the endometrium’s
response to progesterone. |
|
c. |
Hysterosalpingogram is used
to determine if fallopian tubes are patent. |
|
d. |
Serum FSH levels are used
to assess ovarian function. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
27. A
couple who has been attempting to become pregnant for 5 years is seeking
assistance from an infertility clinic. The nurse assesses the clients’
emotional responses to their infertility. Which of the following responses would
the nurse expect to find? (Select all that apply.)
28. Anger
at others who have babies.
29. Feelings
of failure because they cannot make a baby.
30. Sexual
excitement because they want to conceive a baby.
31. Guilt
on the part of one partner because he or she is unable to give the other a
baby.
ANS: a, b, d
|
|
Feedback |
|
a. |
Infertile couples often
feel anger toward couples who have babies. |
|
b. |
Infertile couples often
express feelings of personal failure. |
|
c. |
Infertile couples
undergoing infertility testing and treatment often express an aversion to
sex. |
|
d. |
Guilt is often expressed by
the couple. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
28. Which
of the following places a couple at higher risk for conceiving a child with a
genetic abnormality? (Select all that apply.)
29. Maternal
age over 35 years
30. Partner
who has a genetic disorder
31. Maternal
type 1 diabetes
32. Paternal
heart disease
ANS: a, b
Fertility decreases after 35 years. A partner contributes half
of the chromosomal makeup, and genetic disorders can be inherited. Maternal
diabetes can have an effect on the fetus/neonate, such as causing complications
such as macrosomia and hypoglycemia, but these are not genetic disorders.
Paternal heart disease can place the neonate at risk for heart disease later in
life, but this is not referred to as a genetic disorder, such as is trisomy 21
and hemophilia.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Difficult
29. The
ovarian cycle includes which of the following phases? (Select all that apply.)
30. Follicular
phase
31. Secretory
phase
32. Ovulatory
phase
33. Luteal
phase
34. Menstrual
phase
ANS: a, c, d
Follicular phase, ovulatory phase, and luteal phase are part of
the ovarian cycle. Secretory and menstrual phases are part of the endometrial
cycle.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Adaptation | Difficulty Level: Easy
30. A
couple is undergoing an infertility workup. The semen analysis indicates a
decreased number of sperm and immature sperm. Which of the following factors
can have a potential effect on sperm maturity? (Select all that apply.)
31. The
man rides a bike to and from work each day.
32. The
man takes a calcium channel blocker for the treatment of hypertension.
33. The
man drinks 6 cups of coffee a day.
34. The
man was treated for prostatitis 12 months ago and has been symptom free since
treatment.
ANS: a, b
The daily riding of a bike can be the cause of prolonged heat
exposure to the testicles. Prolonged heat exposure is a gonadotoxin. A number
of medications, such as calcium channel blockers, can have an effect on sperm
production. Coffee has not been associated with low sperm counts. Prostatitis
or other infections within the last 3 months may have an effect on the sperm
analysis. This man’s episode of prostatitis was 12 months prior.
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Application | Content Area: Maternity | Client Need: Health Promotion
and Maintenance | Difficulty Level: Moderate
31. The
clinic nurse recognizes that pregnant women who are in particular need of
support are those who (select all that apply):
32. Are
experiencing a second pregnancy
33. Are
awaiting genetic testing results
34. Are
experiencing a first pregnancy
35. Are
trying to conceal this pregnancy as long as possible
ANS: b, d
A second pregnancy is not an indication of a woman in need of
additional support. A support system may be lacking for women who are trying to
conceal a pregnancy or for women who are trying to keep the news of their
pregnancy from relatives or friends until results from genetic tests are known.
These individuals may need additional support from their nurses and other
health-care providers, as they are placed in a powerless situation while
awaiting results and face a pregnancy that may be in jeopardy.
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client
Need: Safe and Effective Care Environment | Difficulty Level: Moderate
Chapter 4: Physiological Aspects of Antepartum Care
Multiple Choice
1. Folic
acid supplementation during pregnancy is to:a. Improve the bone density of
pregnant women b. Decrease the incidence of neural tube defects in the fetus c.
Decrease the incidence of Down syndrome in the fetusd. Improve calcium uptake
in pregnant women
ANS: b
|
|
Feedback |
|
a. |
Folic acid is not related
to bone density. |
|
b. |
Correct. The use of folic
acid has decreased the incidence of neural tube defects by 50%. |
|
c. |
The use of folic acid is
not associated with a reduction in Down syndrome. |
|
d. |
Folic acid is not related
to calcium uptake in women. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Pharmacological/Parenteral
Therapies | Difficulty Level: Moderate
2. The positive signs of
pregnancy are:a. All physiological and anatomical changes of pregnancyb. All
subjective signs of pregnancyc. All those physiological changes perceived by
the woman herselfd. The objective signs of pregnancy that can only be
attributed to the fetus
ANS: d
|
|
Feedback |
|
a. |
Physiological and
anatomical changes of pregnancy are presumptive signs of pregnancy. |
|
b. |
All subjective signs of
pregnancy are the probable signs of pregnancy. |
|
c. |
All those physiological
changes perceived by the woman herself are presumptive signs of pregnancy. |
|
d. |
Correct. Positive signs of
pregnancy are the objective signs of pregnancy that can only be attributed to
the fetus, such as fetal heart tones. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Knowledge | Content Area: Maternity | Client Need: Physiological
Adaptation | Difficulty Level: Easy
3. During
a routine prenatal visit in the third trimester, a woman reports she is dizzy
and lightheaded when she is lying on her back. The most appropriate nursing
action would be to:a. Order an EKG.
4. Report
this abnormal finding immediately to her care provider.
5. Teach
the woman to avoid lying on her back and to rise slowly because of supine
hypotension.
6. Order
a nonstress test to assess fetal well-being.
ANS: c
|
|
Feedback |
|
a. |
This is a normal occurrence
in pregnancy and does not indicate pathology. The probable cause of the
problem is supine hypotension. |
|
b. |
This is a normal finding
that does not warrant immediate notification to her care provider. |
|
c. |
Correct. Teaching the woman
to avoid lying on her back because of occlusion of the vena cava with the
gravid uterus causes supine hypotension syndrome. |
|
d. |
Antenatal testing is not
indicated with supine hypotension. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Analysis | Content Area: Maternity | Client Need: Physiological
Adaptation | Difficulty Level: Moderate
4. Blood
volume expansion during pregnancy leads to: a. Iron-deficiency anemiab.
Maternal iron stores being insufficient to meet the demands for iron in fetal
developmentc. Plasma fibrin increase of 40% and fibrinogen increase of 50%d.
Physiological anemia of pregnancy
ANS: d
|
|
Feedback |
|
a. |
Iron-deficiency anemia is
treated with iron supplementation. Iron-deficiency anemia is defined as
hemoglobin of less than 11 g/dL and hematocrit less than 33%. |
|
b. |
Maternal iron stores that
are insufficient to meet the demands for iron in fetal development result in
iron-deficiency anemia. |
|
c. |
Hypercoagulation that
occurs during pregnancy is to decrease the risk of postpartum hemorrhage.
These changes taking place are not related to blood volume expansion. |
|
d. |
Correct. Physiological
anemia of pregnancy, also referred to as pseudo-anemia of pregnancy, is due
to hemodilution. The increase in plasma volume is relatively larger than the
increase in RBCs that results in decreased hemoglobin and hematocrit values. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Analysis | Content Area: Maternity | Client Need: Physiological
Adaptation | Difficulty Level: Moderate
5. Intimate
partner violence (IPV) against women consists of actual or threatened physical
or sexual violence and psychological and emotional abuse. Screening for IPV
during pregnancy is recommended for:a. Pregnant women with a history of
domestic violenceb. All pregnant womenc. All low-income pregnant womend.
Pregnant adolescents
ANS: b
|
|
Feedback |
|
a. |
Intimate partner violence
is underreported by women, necessitating universal screening. |
|
b. |
Correct. AWHONN advocates
for universal screening for domestic violence for all pregnant women.
Homicide is the most likely cause of death for pregnant or recently pregnant
women, and a significant portion of those homicides are committed by their
intimate partners. One in six pregnant women reported physical or sexual
abuse during pregnancy, seriously impacting maternal and fetal health and
infant birth weight. |
|
c. |
IPV crosses all ethnic,
racial, religious, and socioeconomic levels. |
|
d. |
IPV crosses all ethnic,
racial, religious, and socioeconomic levels. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Application | Content Area: Maternity | Client Need: Psychosocial
Integrity | Difficulty Level: Moderate
6. A
woman presents to the prenatal clinic at 30 weeks’ gestation reporting dysuria,
frequency, and urgency with urination. Appropriate nursing actions include:a.
Obtain clean-catch urine to assess for a possible urinary tract infection.b.
Reassure the woman that the signs are normal urinary changes in the third
trimester.c. Teach the woman to decrease fluid intake to manage these
symptoms.d. Perform a Leopold’s maneuver to assess fetal position and station.
ANS: a
|
|
Feedback |
|
a. |
Correct. Dysuria,
frequency, and urgency with urination are signs and symptoms of a urinary
tract infection, necessitating further assessment and testing. |
|
b. |
These are abnormal urinary
symptoms in the third trimester. |
|
c. |
Pregnant women need to
increase their fluid intake during pregnancy, and dysuria and urgency are
abnormal. |
|
d. |
Assessment of fetal
position and station is not an appropriate response to reported signs and
symptoms of a urinary tract infection. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Application | Content Area: Maternity | Client Need: Physiological
Adaptation | Difficulty Level: Moderate
7. At
the end of her 32-week prenatal visit, a woman reports discomfort with
intercourse and tells you shyly that she wants to maintain a sexual
relationship with her partner. The best response is to: a. Reassure
woman/couple of normalcy of responseb. Suggest alternative positions for sexual
intercourse and alternative sexual activity to sexual intercoursec. Recommend
cessation of intercourse until after delivery due to advanced gestationd.
Suggest woman discuss this with her care provider at her next appointment
ANS: b
|
|
Feedback |
|
a. |
Although this is a normal
response, providing reassurance is not enough. Further intervention is
indicated. |
|
b. |
Although shy to discuss
this, she wants to maintain a sexual relationship with her partner.
Suggesting alternative positions for sexual intercourse and alternative
sexual activity to sexual intercourse provides the woman with information to
maintain sexual relations. |
|
c. |
She wants to maintain a
sexual relationship with her partner, and there are no contraindications to
intercourse during a healthy pregnancy. |
|
d. |
The patient is seeking out
information and to defer her to her care provider at her next appointment is
inappropriate. Additionally, she may not be comfortable discussing this with
anyone else. |
KEY: Integrated Process: Clinical Problem Solving | Cognitive
Level: Complication | Content Area: Maternity | Client Need: Health Promotion
and Maintenance | Difficulty Level: Moderate
8. The
clinic nurse talks to a 30-year-old woman at 34 weeks’ gestation who complains
of having difficulty sleeping. Jayne has noticed that getting back to sleep
after she has been up at night is difficult. The nurse’s best response is:
9. “This
is abnormal; it is important that you describe this problem to the doctor.”
10. “This
is normal, and many women have this same problem during pregnancy; try napping
for several hours each morning and afternoon.”
11. “This
is abnormal; tell the doctor about this problem because diagnostic testing may
be necessary.”
12. “This
is normal in pregnancy, particularly during the third trimester when you also
feel fetal movement at night; try napping once a day.”
ANS: d
|
|
Feedback |
|
a. |
This sleep pattern is a
normal finding. |
|
b. |
Sleeping for several hours
in the morning and afternoon would contribute to further sleep disturbances
at night. |
|
c. |
This sleep pattern is a
normal finding. |
|
d. |
Pregnancy sleep patterns
are characterized by reduced sleep efficiency, fewer hours of night sleep,
frequent awakenings, and difficulty going to sleep. Nurses can advise
patients that afternoon napping may help alleviate the fatigue associated
with the sleep alterations. |
KEY: Integrated Process: Teaching and Learning | Cognitive
Level: Application | Content Area: Maternity | Client Need: Health Promotion
and Maintenance | Difficulty Level: Moderate
9. A
26-year-old woman at 29 weeks’ gestation experienced epigastric pain following
the consumption of a large meal of fried fish and onion rings. The pain
resolved a few hours later. The most likely diagnosis for this symptom is:
10. Cholelithiasis
11. Influenza
12. Urinary
tract infection
13. Indigestion
ANS: a
|
|
Feedback |
|
a. |
The progesterone-induced
prolonged emptying time of bile from the gallbladder, combined with elevated
blood cholesterol levels, may predispose the pregnant woman to gallstone
formation (cholelithiasis). Pain in the epigastric region following ingestion
of a high-fat meal constitutes the major symptom of these conditions. The
pain is self-limiting and usually resolves within 2 hours. |
|
b. |
The symptoms described are
not associated with influenza. |
|
c. |
The symptoms described are
not associated with urinary tract infection. |
|
d. |
Prolonged emptying time of
bile from the gallbladder, combined with elevated blood cholesterol levels,
make cholelithiasis a more probable diagnosis than indigestion. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Application | Content Area: Maternity | Client Need:
Health Promotion and Maintenance | Difficulty Level: Moderate
10. The
clinic nurse reviews the complete blood count results for a 30-year-old woman
who is now 33 weeks’ gestation. Tamara’s hemoglobin value is 11.2 g/dL, and her
hematocrit is 38%. The clinic nurse interprets these findings as:
11. Normal
adult values
12. Normal
pregnancy values for the third trimester
13. Increased
adult values
14. Increased
values for 33 weeks’ gestation
ANS: b
|
|
Feedback |
|
a. |
The values are low normal
for adults but represent normal findings for pregnant women. |
|
b. |
During pregnancy the
woman’s hematocrit values may appear low due to the increase in total plasma
volume (on average, 50%). Because the plasma volume is greater than the
increase in erythrocytes (30%), the hematocrit decreases by about 7%. This
alteration is termed “physiologic anemia of pregnancy,” or “pseudo-anemia.”
The hemodilution effect is most apparent at 32 to 34 weeks. The mean
acceptable hemoglobin level in pregnancy is 11 to 12 g/dL of blood. |
|
c. |
The values are not
increased; they are low normal for adults but represent normal findings for
pregnant women. |
|
d. |
The values are not
increased; they are low normal for adults but represent normal findings for
pregnant women. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Analysis | Content Area: Peds/Maternity | Client
Need: Safe and Effective Care Environment | Difficulty Level: Difficult
11. The
clinic nurse is aware that the pregnant woman’s blood volume increases by:
12. 20%
to 25%
13. 30%
to 35%
14. 40%
to 45%
15. 50%
to 55%
ANS: c
|
|
Feedback |
|
a. |
An increase in maternal
blood volume begins during the first trimester and peaks at term. The
increase approaches 40% to 45%, not 20% to 25%. |
|
b. |
An increase in maternal
blood volume begins during the first trimester and peaks at term. The
increase approaches 40% to 45, not 30% to 35%. |
|
c. |
An increase in maternal
blood volume begins during the first trimester and peaks at term. The
increase approaches 40% to 45% and is primarily due to an increase in plasma
and erythrocyte volume. Additional erythrocytes, needed because of the extra
oxygen requirements of the maternal and placental tissue, ensure an adequate
supply of oxygen to the fetus. The elevation in erythrocyte volume remains
constant during pregnancy. |
|
d. |
An increase in maternal
blood volume begins during the first trimester and peaks at term. The
increase approaches 40% to 45%, not as high as 50% to 55%. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client
Need: Safe and Effective Care Environment | Difficulty Level: Easy
12. The
clinic nurse uses Leopold maneuvers to determine the fetal lie, presentation,
and position. The nurse’s hands are placed on the maternal abdomen to gently
palpate the fundal region of the uterus. This action is best described as the:
13. First
maneuver
14. Second
maneuver
15. Third
maneuver
16. Fourth
maneuver
ANS: a
|
|
Feedback |
|
a. |
Leopold maneuvers are a
four-part clinical assessment method used to determine the lie, presentation,
and position of the fetus. The first maneuver determines which fetal body
part (e.g., head or buttocks) occupies the uterine fundus. The examiner faces
the patient’s head and places the hands on the abdomen, using the palmar
surface of the hands to gently palpate the fundal region of the uterus. The
buttocks feel soft, broad, and poorly defined and move with the trunk. The
fetal head feels firm and round and moves independently of the trunk. |
|
b. |
Leopold maneuvers are a
four-part clinical assessment method used to determine the lie, presentation,
and position of the fetus. The first maneuver is described in this scenario. |
|
c. |
Leopold maneuvers are a four-part
clinical assessment method used to determine the lie, presentation, and
position of the fetus. The first maneuver is described in this scenario. |
|
d. |
Leopold maneuvers are a
four-part clinical assessment method used to determine the lie, presentation,
and position of the fetus. The first maneuver is described in this scenario. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Application | Content Area: Maternity | Client Need:
Safe and Effective Care Environment | Difficulty Level: Moderate
13. The
clinic nurse talks with Kathy about her possible pregnancy. Kathy has
experienced amenorrhea for 2 months, nausea during the day with vomiting every
other morning, and breast tenderness. These symptoms are best described as:
14. Positive
signs of pregnancy
15. Presumptive
signs of pregnancy
16. Probable
signs of pregnancy
17. Possible
signs of pregnancy
ANS: b
|
|
Feedback |
|
a. |
Positive signs include
fetal heartbeat, visualization of the fetus, and fetal movements palpated by the
examiner. |
|
b. |
Presumptive signs of
pregnancy include amenorrhea, nausea and vomiting, frequent urination, breast
tenderness, perception of fetal movement, skin changes, and fatigue. Probable
signs of pregnancy include abdominal enlargement, Piskacek sign, Hegar sign,
Goodell sign, Braxton Hicks sign, positive pregnancy test, and ballottement.
Positive signs include fetal heartbeat, visualization of the fetus, and fetal
movements palpated by the examiner. |
|
c. |
Probable signs of pregnancy
include abdominal enlargement, Piskacek sign, Hegar sign, Goodell sign,
Braxton Hicks sign, positive pregnancy test, and ballottement. |
|
d. |
Possible signs of pregnancy
may vary widely. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Application | Content Area: Maternity | Client Need:
Safe and Effective Care Environment | Difficulty Level: Moderate
14. Lina
is an 18-year-old woman at 20 weeks’ gestation. This is her first pregnancy.
Lina is complaining of fatigue and listlessness. Her vital signs are within a
normal range: BP = 118/60, pulse = 70, and respiratory rate 16 breaths per
minute. Lina’s fundal height is at the umbilicus, and she states that she is
beginning to feel fetal movements. Her weight gain is 25 pounds over the
prepregnant weight (110 lb), and her height is 5 feet 4 inches. The perinatal
nurse’s best approach to care at this visit is to:
15. Ask
Lina to keep a 3-day food diary to bring in to her next visit in 1 week.
16. Explain
to Lina that weight gain is not a concern in pregnancy, and she should not
worry.
17. Teach
Lina about the expected normal weight gain during pregnancy (approximately 20
pounds by 20 weeks’ gestation).
18. Explain
to Lina the possible concerns related to excessive weight gain in pregnancy, including
the risk of gestational diabetes.
ANS: a
|
|
Feedback |
|
a. |
Nutrition and weight
management play an essential role in the development of a healthy pregnancy.
Not only does the patient need to have an understanding of the essential nutritional
elements, she must also be able to assess and modify her diet for the
developing fetus and her own nutritional maintenance. To facilitate this
process, it is the nurse’s responsibility to provide education and counseling
concerning dietary intake, weight management, and potentially harmful
nutritional practices. To facilitate this process, it is the nurse’s
responsibility to gather more information on the woman’s dietary practices
through a food diary. |
|
b. |
Nutrition and weight
management play an essential role in the development of a healthy pregnancy.
To facilitate this process, it is the nurse’s responsibility to provide
education and counseling concerning dietary intake, weight management, and
potentially harmful nutritional practices. |
|
c. |
Nutrition and weight
management play an essential role in the development of a healthy pregnancy.
Not only does the patient need to have an understanding of the essential
nutritional elements, she must also be able to assess and modify her diet for
the developing fetus and her own nutritional maintenance. To facilitate this
process, it is the nurse’s responsibility to provide education and counseling
concerning dietary intake, weight management, and potentially harmful
nutritional practices, not just inform the patient of expected normal weight
gain. |
|
d. |
Nutrition and weight management play an
essential role in the development of a healthy pregnancy. Not only does the
patient need to have an understanding of the essential nutritional elements,
she must also be able to assess and modify her diet for the developing fetus
and her own nutritional maintenance. To facilitate this process, it is the
nurse’s responsibility to provide education and counseling concerning dietary
intake, weight management, and potentially harmful nutritional practices. |
KEY: Integrated Process: Nursing Process: Clinical Problem
Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client
Need: Safe and Effective Care Environment | Difficulty Level: Moderate
15. A
woman presents to a prenatal clinic appointment at 10 weeks’ gestation, in the
first trimester of pregnancy. Which of the following symptoms would be
considered a normal finding at this point in pregnancy?
16. Occipital
headache
17. Urinary
frequency
18. Diarrhea
19. Leg
cramps
ANS: b
|
|
Feedback |
|
a. |
Headaches may be benign or,
especially if noted after 20 weeks’ gestation, may be a symptom of
pregnancy-induced hypertension (PIH). |
|
b. |
Urinary frequency is a
common complaint of women during their first trimester. |
|
c. |
Diarrhea is rarely seen in
pregnancy. Constipation is a common complaint. |
|
d. |
Leg cramps are commonly
seen during the second and third trimesters. |
KEY: Integrated Process: Nursing Process: Assessment | Cognitive
Level: Comprehension | Content Area: Antepartum Care | Client Need: Health
Promotion and Maintenance | Difficulty Level: Easy
16. The
nurse is providing prenatal teaching to a group of diverse pregnant women. One
woman, who indicates she smokes two to three cigarettes a day, asks about its
impact on her pregnancy. The nurse explains that the most significant risk to
the fetus is:
17. Respiratory
distress at birth
18. Severe
neonatal anemia
19. Low
neonatal birth weight
20. Neonatal
hyperbilirubinemia
ANS: C
|
|
Feedback |
|
a. |
Respiratory distress is not
the most significant risk to the fetus unless the fetus is also premature. |
|
b. |
Severe neonatal anemia is
not associated with pregnancies complicated by cigarette smoking. |
|
c. |
Low neonatal birth weight
is the most common complication seen in pregnancies complicated by cigarette
smoking. |
|
d. |
Neonatal hyperbilirubinemia
is not associated with pregnancies complicated by cigarette smoking. |
KEY: Integrated Process: Nursing Process: Implementation;
Teaching and Learning | Cognitive Level: Application | Content Area: Antepartum
Care; Growth and Development | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
17. While
performing Leopold’s maneuvers on a woman in early labor, the nurse palpates a
flat area in the fundal region, a hard round mass on the left side, a soft
round mass on the right side, and small parts just above the symphysis. The
nurse concludes which of the following?
18. The
fetal position is right occiput posterior.
19. The
fetal attitude is flexed.
20. The
fetal presentation is scapular.
21. The
fetal lie is vertical.
ANS: c
|
|
Feedback |
|
a. |
This is a shoulder
presentation. |
|
b. |
It is not possible to
determine whether the attitude is flexed or not when doing Leopold’s
maneuvers. |
|
c. |
This is a shoulder
presentation. |
|
d. |
The lie is transverse or
horizontal. |
KEY: Integrated Process: Nursing Process: Analysis; Nursing
Process: Assessment | Cognitive Level: Application | Content Area: Antepartum
Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy
18. A
nurse is reviewing diet with a pregnant woman in her second trimester. Which of
the following foods should the nurse advise the patient to avoid consuming
during her pregnancy?
19. Brie
cheese
20. Bartlett
pears
21. Sweet
potatoes
22. Grilled
lamb
ANS: a
|
|
Feedback |
|
a. |
Soft cheese may
harbor Listeria.
The patient should avoid consuming uncooked soft cheese. |
|
b. |
A pear is an excellent food
for a pregnant woman to consume. |
|
c. |
Sweet potatoes are an
excellent food for a pregnant woman to consume. |
|
d. |
Grilled lamb is an
excellent food for a pregnant woman to consume, although it should be well
cooked. |
KEY: Integrated Process: Nursing Process: Implementation;
Teaching and Learning | Cognitive Level: Application | Content Area: Antepartum
Care; Reduction of Risk Potential: Potential for Alterations in Body Systems |
Client Need: Health Promotion and Maintenance; Physiological Integrity:
Reduction of Risk Potential | Difficulty Level: Moderate
19. The
nurse is working in a prenatal clinic caring for a patient at 14 weeks’
gestation, G2 P1001. Which of the following findings should the nurse highlight
for the nurse midwife?
20. Body
mass index of 23
21. Blood
pressure of 100/60
22. Hematocrit
of 29%
23. Pulse
rate of 76 bpm
ANS: c
|
|
Feedback |
|
a. |
A body mass index of 23 is
normal. |
|
b. |
A blood pressure of 100/60
is normal. |
|
c. |
A hematocrit of 29%
indicates that the patient is anemic. The nurse should highlight the finding
for the nurse-midwife. |
|
d. |
A pulse rate of 76 bpm is a
normal rate. |
KEY: Integrated Process: Nursing Process: Implementation | Cognitive
Level: Application | Content Area: Antepartum Care; Potential for Alterations
in Body Systems; Reduction of Risk Potential: Laboratory Values | Client Need:
Health Promotion and Maintenance: Antepartum Care; Physiological Integrity:
Reduction of Risk Potential | Difficulty Level: Easy
20. A
gravida, G4 P1203, fetal heart rate 150s, is 14 weeks pregnant, fundal height 1
cm above the symphysis. She denies experiencing quickening. Which of the
following nursing conclusions made by the nurse is correct?
21. The
woman is experiencing a normal pregnancy.
22. The
woman may be having difficulty accepting this pregnancy.
23. The
woman must see a nutritionist as soon as possible.
24. The
woman will likely miscarry the conceptus.
ANS: a
|
|
Feedback |
|
a. |
The patient is experiencing
a normal pregnancy. |
|
b. |
Quickening is not felt
until 16 to 20 weeks’ gestation. |
|
c. |
There is no apparent need
for a nutritionist to see this patient. |
|
d. |
There is no indication in
the scenario that this patient is at high risk for a miscarriage. |
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