Chapter 13: Adaptations to Pregnancy McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition

A pregnant woman's mother is worried that her daughter is not "big enough" at 20 weeks. The

nurse palpates and measures the fundal height at 20 cm, which is even with the woman's

umbilicus. What should the nurse report to the woman and her mother?

a. "The body of the uterus is at the belly button level, just where it should be at

this time."

b. c. "You're right. We'll inform the practitioner immediately."

"When you come for next month's appointment, we'll check you again to

make sure that the baby is growing."

d. "Lightening has occurred, so the fundal height is lower than expected."

ANS: A

At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows

in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks of

gestation is located at the level of the umbilicus. There is no need to inform the practitioner.

The nurse should reassure both mother and patient that the findings are normal. The descent

of the fetal head (lightening) occurs in late pregnancy.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 214 | p. 229 OBJ: Nursing Process: Implementation

While the nurse assesses the vital signs of a pregnant woman in her third trimester, the patient

complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?

A. Have the patient stand up and retake her blood pressure.

B. Have the patient sit down and hold her arm in a dependent position.

C. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms.

d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.

ANS: D

Blood pressure is affected by positions during pregnancy. The supine position may cause

occlusion of the vena cava and descending aorta. Turning the pregnant woman to a

lateral recumbent position alleviates pressure on the blood vessels and quickly corrects

supine hypotension. Pressures are significantly higher when the patient is standing. This

option causes an increase in systolic and diastolic pressures. The arm should be

supported at the same level of the heart. The supine position may cause occlusion of the

vena cava and descending aorta, creating hypotension.

PTS: 1 DIF: Cognitive Level: Application/Applying

A pregnant woman has come to the emergency department with complaints of nasal

congestion and epistaxis. What action by the nurse is best?

a. Refer the patient to an ear, nose, and throat specialist

b. Explain that nasal stuffiness and nosebleeds are caused by a decrease in

progesterone.

c. Attach the woman to a cardiac monitor, and draw blood for hemoglobin

and hematocrit.

d. Teach that the increased blood supply to the mucous membranes and can result in congestion and nosebleeds.

ANS: D

As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema

and hyperemia, which causes these conditions, seen commonly during pregnancy. No referral is

needed. The patient does not need to be attached to a cardiac monitor or have lab drawn. The

patient should be taught that estrogen causes these changes, not progesterone.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 218 OBJ: Integrated Process: Teaching-Learning

MSC: Client Needs: Physiologic Integrity

Which finding in the urine analysis of a pregnant woman is considered a variation of normal?

a. Proteinuria

b. Glycosuria

c. Bacteria

d. Ketonuria

ANS: B

Small amounts of glucose may indicate "physiologic spilling," which occurs because the

filtered load exceeds the renal tubules' ability to absorb them. The presence of protein could

indicate kidney disease or preeclampsia. Urinary tract infections are associated with

bacteria in the urine. An increase in ketones indicates that the patient is exercising too

strenuously or has an inadequate fluid and food intake.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 219 OBJ: Nursing Process: Assessm

Which suggestion is appropriate for the pregnant woman who is experiencing nausea

and vomiting?

A. Eat only three meals a day so the stomach is empty between meals.

B. Drink plenty of fluids with each meal.

C. Eat dry crackers or toast before arising in the morning.

D. Drink coffee or orange juice immediately on arising in the morning.

ANS: C

This will assist with the symptoms of morning sickness. It is also important for the woman

to arise slowly. Instruct the woman to eat five to six small meals rather than three full meals

per day. Nausea is more intense when the stomach is empty. Fluids should be taken

separately from meals. Fluids overstretch the stomach and may precipitate vomiting. Coffee

and orange juice stimulate acid formation in the stomach. It is best to suggest eating dry

carbohydrates when rising in the morning.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 230 OBJ: Nursing Process

Which statement related to changes in the breasts during pregnancy is the most accurate?

A. During the early weeks of pregnancy there is decreased sensitivity.

B. Nipples and areolae become more pigmented.

C. Montgomery tubercles are no longer visible around the nipples.

D. Venous congestion of the breasts is more visible in the multiparous woman.

ANS: B

Nipples and areolae become more pigmented, and the nipples become more erectile and may

express colostrum. Fullness, heightened sensitivity, tingling, and heaviness of the breasts

occur in the early weeks of gestation in response to increased levels of estrogen and

progesterone. Montgomery tubercles may be seen around the nipples. These sebaceous

glands may have a protective role in that they keep the nipples lubricated for breastfeeding.

Venous congestion in the breasts is more obvious in primigravidas.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

A student nurse reads a patient's chart and sees the term "striae gravidarum," The student asks

the registered nurse what this means. What response by the nurse is accurate?

A. Stretch marks on the abdomen and breasts

B. Dark pigmentation on the woman's face

C. Bluish-purple discoloration of the vagina and labia

D. Reddened bleeding gums in a pregnant woman

ANS: A

Stretch marks occurring on the abdomen and/or breasts of a pregnant woman are called striae

gravidarum. Dark pigmentation on the face is known as melisma, chloasma, or the mask of

pregnancy. The bluish tint to the vagina and labia is known as Chadwick's sign. Reddened and

bleeding gums are known as gingivitis in both pregnant and non-pregnant women.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to

A. compensate for decreased renal plasma flow.

B. provide adequate perfusion of the placenta.

C. eliminate metabolic wastes of the mother.

D. prevent maternal and fetal dehydration.

ANS: B

The primary function of increased vascular volume is to transport oxygen and nutrients to

the fetus via the placenta. Renal plasma flow increases during pregnancy. Assisting with

pulling metabolic wastes from the fetus for maternal excretion is one purpose of the

increased vascular volume. However, this answer is not the best because it doesn't explain

the overall purpose and only includes one purpose. Prevention of dehydration is not the

reason for increased vascular volume.

PTS: 1 DIF: Cognitive Level: Knowledge/Rememberi

A nurse is taking vital signs on a pregnant woman. Preconception pulse was 76 beats/minute.

Today the pulse is 97 beats/minute. What action by the nurse is best?

a. Inform the provider immediately.

b. Document findings in the chart.

c. Prepare to start an IV infusion.

d. Retake the pulse in 15 minutes.

ANS: B

The pulse of a pregnant woman increases about 15 to 20 beats/minute throughout the

pregnancy. The nurse should document the findings, but no other actions are needed as this is

a normal finding.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 216 OBJ: Nursing Process: Implem

Physiologic anemia often occurs during pregnancy as a result of

a. inadequate intake of iron.

b. dilution of hemoglobin concentration.

c. the fetus establishing iron stores.

d. decreased production of erythrocytes.

ANS: B

When blood volume expansion is more pronounced and occurs earlier than the increase in

red blood cells, the woman will have physiologic anemia, which is the result of dilution of

hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may

lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may

occur when the fetus pulls stored iron from the maternal system. There is an increased

production of erythrocytes during pregnancy.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 216 OBJ: Nursing Process: Assessm

While assessing her patient, what does the nurse interpret as a positive sign of pregnancy?

a. Fetal movement felt by the woman

b. Amenorrhea

c. Breast changes

d. Visualization of fetus by ultrasound

ANS: D

The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of

the fetus by ultrasound, and fetal movement felt by the examiner. Fetal movement felt by the

woman, amenorrhea, and breast changes are all presumptive signs.

PTS: 1 DIF: Cognitive Level: Knowledge/Comprehension

A woman is currently pregnant; she has a 5-year-old son and a 3-year-old daughter born at full

term. She had one other pregnancy that terminated at 8 weeks. Her gravida and para are

a. gravida 3 para 2.

b. gravida 4 para 3.

c. gravida 4 para 2.

d. gravida 3 para 3.

ANS: C

She has had four pregnancies, including the current one (gravida 4). She had two pregnancies

that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is

classified as an abortion, which is not included in the gravida-para classification.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 225 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

A woman's last menstrual period was June 10. The nurse estimates the date of delivery (EDD)

to be

a. April 7.

b. March 17.

c. March 27.

d. April 17.

ANS: B

To determine the EDD, the nurse uses the first day of the last menstrual period (June 10),

subtracts 3 months (March 10), and adds 7 days (March 17). The year is corrected if needed.

April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days

instead of adding 7 days. March is the correct month, but instead of adding 7 days, 17 days

were added to get March 27. April 17 is subtracting 2 months instead of 3 months.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 225 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

A nurse sees a woman in her first trimester of pregnancy. The nurse explains that the woman

can expect to visit her physician every 4 weeks so that

a. she develops trust in the health care team.

b. her questions about labor can be answered.

c. the condition of the mother and fetus can be monitored.

d. problems can be eliminated.

ANS: C

This routine allows monitoring of maternal health and fetal growth and ensures that problems

will be identified early. If the woman begins prenatal care in the first trimester, every 4 weeks

is the recommended schedule for visits. Developing a trusting relationship should be

established during these visits, but that is not the primary reason. Most women do not have

questions concerning labor until the last trimester of the pregnancy. All problems cannot be

eliminated because of prenatal visits, but they can be identified.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 228 OBJ: Nursing Process: Assessment

A patient in her first trimester complains of nausea and vomiting. She asks, "Why does this happen?" The nurse's best response is

a. "It is due to an increase in gastric motility."

b. "It may be due to changes in hormones."

c. "It is related to an increase in glucose levels."

d. "It is caused by a decrease in gastric secretions."

ANS: B

Nausea and vomiting are believed to be caused by increased levels of hormones and

decreased gastric motility. Glucose levels decrease in the first trimester. Hypoglycemia, if

experienced, can also lead to nausea. Gastric secretions do decrease, but this is not the main

cause of nausea and vomiting.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 231 OBJ: Integrated Process: Teaching-Learning

The nurse teaches a pregnant woman that one of the most effective methods for

preventing venous stasis is to

a. wear elastic stockings in the afternoons.

b. sleep with the foot of the bed elevated.

c. rest often with the feet elevated.

d. sit with the legs crossed.

ANS: C

Elevating the feet and legs improves venous return and prevents venous stasis. Elastic

stockings should be applied before lowering the legs in the morning. Elevating the legs at

night may cause pressure on the diaphragm and increase breathing problems. Sitting with

the legs crossed will decrease circulation in the legs and increase venous stasis.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 230 OBJ: Integrated Pr

A patient notices that the doctor writes "positive Chadwick's sign" on her chart. She asks the nurse what this means. The nurse's best response is

A. "It refers to the bluish color of the cervix in pregnancy."

B. "It means the cervix is softening."

C. "The doctor was able to flex the uterus against the cervix."

D. "That refers to a positive sign of pregnancy."

ANS: A

Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the

cervix, vagina, and labia, called Chadwick's sign. The nurse should also know that this is a

presumptive, not positive, sign of pregnancy. Softening of the cervix is Goodell's sign. The

softening of the lower segment of the uterus (Hegar's sign) can allow the uterus to be

flexed against the cervix.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 215 OBJ: Integrated Process: Teaching-Learning

A woman is at her first prenatal visit and is distressed at needing an HIV test. What response

by the nurse is best?

A. "We ask all women to be tested for HIV during their pregnancy."

B. "This test is required by law for pregnant women."

C. "Infection with HIV will make your pregnancy very high risk."

D. "You could have been exposed and not know it."

ANS: A

A voluntary HIV test should be conducted on all women, regardless of risk factors. This

explanation is accurate and helps lessen the woman's feeling of stigma. It also lets the woman

know it is voluntary. The test is not required by law. Although an HIV infection will increase the

risk of complications, this explanation is too limited to be a good answer. It is true the woman

may have been exposed, but that comment is demeaning and could be offensive.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: Table 13.3 OBJ: Integrated Process: Teaching-Lea

To relieve a leg cramp, the patient should be instructed to

a. massage the affected muscle.

b. stretch and point the toe.

c. dorsiflex the foot.

d. apply a warm pack.

ANS: C

Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle

contraction. Since she is prone to blood clots in the legs, massaging the affected leg muscle

is contraindicated. Pointing the toes will contract the muscle and not relieve the pain. Warm

packs can be used to relax the muscle, but more immediate relief is necessary, such as

dorsiflexion of the foot.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 231 OBJ: Integrated Process: Teaching-Learn

The multiple marker screen is used to assess the fetus for which condition?

a. Down syndrome

b. Diaphragmatic hernia

c. Congenital cardiac abnormality

d. Anencephaly

ANS: A

The maternal serum level of alpha- fetoprotein is used to screen for trisomy 18 or 21 and

neural tube defects. The quadruple marker test does not detect hernias. Additional testing,

such as ultrasonography, would be required to diagnose diaphragmatic hernia. Congenital

cardiac abnormality would most likely be identified during an ultrasound examination.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: Table 13.3 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

A nurse is caring for patients in the prenatal clinical who are all 35 weeks along. Which

patient should the nurse see first?

a. Shortness of breath when climbing stairs

b. Abdominal pain

c. Ankle edema in the afternoon

d. Backache with prolonged standing

ANS: B

Abdominal pain may indicate preterm labor or placental abruption so this patient should

be seen first. Shortness of breath climbing stairs, afternoon ankle edema, and backache are

all normal findings at this stage of pregnancy.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 236 OBJ: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

A patient at 32 weeks of gestation reports that she has severe lower back pain. The nurse's

assessment should include

a. observation of posture and body mechanics.

b. palpation of the lumbar spine.

c. exercise pattern and duration.

d. ability to sleep for at least 6 hours uninterrupted.

ANS: A

Correct posture and body mechanics can reduce lower back pain caused by increasing

lordosis. Pregnancy should not cause alterations in the spine. Any assessment for

malformation should be done early in the pregnancy. Exercise and sleep are not as

important to assess as are posture and body mechanics, which can contribute to the pain.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 230 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an

expectant parent's class. Which aspect of their birth plan would require further discussion

with the nurse?

a. "My husband and I have agreed that my sister will be my coach."

b. "We plan to use Lamaze to reduce the pain during labor."

c. "We want the labor and birth to take place in a birthing room with our son present.

d. "We will not use the fetal monitor during labor."

ANS: D

A birth plan consists of what the woman and partner wish to have happen during labor and

delivery. Intermittent or continuous fetal monitoring is one aspect of care for consideration;

however, it is unrealistic to state that monitoring will not be used. The nurse should explain

the purpose to ensure the couple is making an informed decision. The woman can refuse

this procedure but would need to understand how this might negatively impact her child.

The couple also need to understand that the entire plan is tentative depending on what

events actually occur. The other statements are appropriate for a birth plan.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: Box 13.2 OBJ: Nursing Process: Implementation

A couple ask the prenatal nurse to explain centering pregnancy. Which statement accurately

applies to this model of care?

a. A way to control labor pain and remain centered during the process

b. A philosophy of making the pregnancy the center of the family's life

c. Education and support sessions are provided to small cohorts of women

d. Labor practice where the woman is surrounded by an extensive network of people

ANS: C

This method involves ten 1.5- to 2-hour sessions with small groups of women and health

care providers beginning at 12 to 16 weeks of pregnancy and ending in early postpartum.

Sessions include assessment, education, and social support. It is not a way to control labor

pain, a philosophy of making the pregnancy the center of the family's life, or the use of a

large network of people during labor.

PTS: 1 DIF: Cognitive Level: Application REF: p. 228

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which comment by a woman in her first trimester indicates ambivalent feelings?

A. "I wanted to become pregnant, but I'm scared about being a mother."

B. "I haven't felt well since this pregnancy began."

C. "I'm concerned about the amount of weight I've gained."

D. "My body is changing so quickly."

ANS: A

Ambivalence refers to conflicting feelings. This woman is demonstrating this conflict.

The other statements do not indicate ambivalence.

PTS: 1 DIF: Cognitive Level: Analysis/Analyzing

REF: p. 236 OBJ: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

A patient who is 7 months pregnant states, "I'm worried that something will happen to my baby." The nurse's best response is

a. "There is nothing to worry about."

b. "The doctor is taking good care of you and your baby."

c. "Tell me about your concerns."

d. "Your baby is doing fine."

ANS: C

Encouraging the client to discuss her feelings is the best approach. Women during their third

trimester need reassurance that such fears are not unusual in pregnancy. An open-ended

request to share information will encourage the patient to explain concerns further. The other

statements belittle the patient's concerns and provide false hope.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 238 OBJ: Integrated Process: Communication and Docu

Which of the following behaviors by a pregnant woman would be an example of

mimicry?

A. Babysitting for a neighbor's children

B. Wearing maternity clothes before they are needed

c. Daydreaming about the newborn

D. Imagining oneself as a good mother

ANS: B

Mimicry refers to observing and copying the behaviors of others, in this case, other pregnant

women. Wearing maternity clothes before they are needed helps the expectant mother "feel"

what it's like to be obviously pregnant. Babysitting other children is a form of role playing

where the woman practices the expected role of motherhood. Daydreaming is a type of fantasy

where the woman "tries on" a variety of behaviors in preparation for motherhood. Imagining

herself as a good mother is the woman's effort to look for a good role fit. She observes behavior

of other mothers and compares them with her own expectations.

PTS: 1 DIF: Cognitive Level: Comprehension/Understa

A step in maternal role attainment that relates to the woman giving up certain aspects of her

previous life is termed

a. looking for a fit.

b. role playing.

c. fantasy.

d. grief work.

ANS: D

The woman experiences sadness as she realizes that she must give up certain aspects of her

previous self and that she can never go back. Looking for a fit is when the woman

observes the behaviors of mothers and compares them with her own expectations. Role

playing involves searching for opportunities to provide care for infants in the presence of

another person. Fantasies allow the woman to try on a variety of behaviors. This usually

deals with how the child will look and the characteristics of the child.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 240 OBJ: Nursing Process: Ass

The maternal task that begins in the first trimester and continues throughout the

neonatal period is called

a. seeking safe passage for herself and her baby.

b. securing acceptance of the baby by others.

c. learning to give of herself.

d. developing attachment with the baby.

ANS: D

Developing attachment (strong ties of affection) to the unborn baby begins in early pregnancy

when the woman accepts that she is pregnant. By the second trimester, the baby becomes

real, and feelings of love and attachment surge. Seeing safe passage is a task that ends with

delivery. During this task the woman seeks health care and cultural practices. Securing

acceptance continues throughout pregnancy as the woman reworks relationships. Learning to

give of herself occurs during pregnancy and is sometimes noticed as the woman gives to

others in the form of food or presents.

PTS: 1 DIF: Cognitive Level: Knowledge/Remember

Which situation best describes a man "trying on" fathering behaviors?

A. Spending more time with his siblings

B. Taking a nephew to the park to play

C. Reading books on newborn care

D. Exhibiting physical symptoms related to pregnancy

ANS: B

Interacting with children and assuming the behavior and role of a father best describe a man

"trying on" being a father. The man normally will seek closer ties with his father during this

time, not his siblings. While some fathers do everything they can to learn about infant care,

others are not ready to learn when the information is presented, so the nurse should provide

the information again after the baby is born and it is more relevant. Exhibiting symptoms

related to pregnancy is called couvade.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

A 36-year-old divorcee with a successful modeling career finds out that her 18-year-old

married daughter is expecting her first child. What is a major factor in determining how

the woman will respond to becoming a grandmother?

a. Her career

b. Being divorced

c. Her age

d. Age of the daughter

ANS: C

Age is a major factor in determining the emotional response of prospective grandparents.

Young grandparents may not be happy with the stereotype of grandparents as being old.

Career responsibilities may have demands that make the grandparents not as accessible, but

it is not a major factor in determining the woman's response to becoming a grandmother.

Being divorced is not a major factor that determines adaptation of grandparents. The age of

the daughter is not a major factor that determines adaptation of grandparents. The age of the

grandparent is a major factor.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 242

The nurse who practices in a prenatal clinic understands that a major concern of

lower socioeconomic groups is to

a. maintain group health insurance on their families.

b. meet health needs as they occur.

c. practice preventive health care.

d. maintain an optimistic view of life.

ANS B

Because of economic uncertainty, lower socioeconomic groups place more emphasis on

meeting the needs of the present rather than on future goals. Lower socioeconomic

groups usually do not have group health insurance. They may value health care but

cannot afford preventive health care. They may struggle for basic needs and often do not

see a way to improve their situation. It is difficult to maintain optimism.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: Table 13.6 OBJ: Nursing Process: Assessmen

What comment by a new mother exhibits understanding of her toddler's response to a

new sibling?

a. "I can't believe he is sucking his thumb again."

b. "He is being difficult, and I don't have time to deal with him."

c. "My husband will stay with the baby so I can take our son to the park."

d. "When we brought the baby home, we made our son stop sleeping in the crib."

ANS: C

It is important for a mother to seek time alone with her toddler to reassure him that he is

loved. Toddlers can feel jealous and resentful having to share the mother's attention. It is

normal for a child to regress when a new sibling is introduced into the home. As difficult as it

is, the mother must make time to spend with the toddler. Changes in sleeping arrangements

should be made several weeks before the birth so that the child does not feel displaced by the

new baby.

PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating

A nurse in labor and delivery is caring for a Muslim woman during the active phase of labor.

You note that when you touch her, she quickly draws away. Which response by the nurse is

best?

A. Continue to touch her as much as you need to while providing care.

B. Assume that she doesn't like you and decrease your time with her.

C. Limit touching to a minimum, as this may not be acceptable in her culture.

D. Ask the charge nurse to reassign you to another patient.

ANS: C

Touching is an important component of communication in various cultures, but if the patient

appears to find it offensive, the nurse should respect her cultural beliefs and limit touching

her. By continuing to touch her, the nurse is showing disrespect for her cultural beliefs. A

cultural response to touch does not reflect like or dislike. Being assigned to another patient

is inappropriate; all nurses must be able to provide culturally appropriate care.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 246 OBJ: Integrated Process: Culture and S

A nurse is encouraging a patient to attend an early pregnancy class for the second trimester.

What topic would be inconsistent with the nurse's knowledge of topics presented in this

class?

a. Fetal development

b. Body mechanics

c. Childbirth choices

d. Managing morning sickness

ANS: D

Managing morning sickness would be taught in a first trimester early pregnancy class. The

other topics are appropriate for second trimester classes.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 231 OBJ: Integrated Process: Teaching-Learning

MSC: Client Needs: Health Promotion and Maintenanc

A pregnant patient of 28 weeks' gestation complains of pain in the right inguinal area. What

action by the nurse is best?

a. Assess the woman for early labor.

b. Position the woman on the right side.

c. Palpate the woman's abdomen.

d. Document the findings in the chart.

ANS: B

Pain in the right inguinal area is most likely due to the round ligament. The nurse can position

the woman on her right side to see if that relieves the pain. Heat can also help. There is no

need to assess for labor or palpate the abdomen. The findings should be documented after the

nurse responds.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 230 OBJ: Nursing Process: Implementation

A student nurse is teaching a pregnant woman ways to manage constipation. Which

instruction by the student causes the nurse to provide a correction?

A. Drink at least 8 glasses of liquids a day.

B. The fat in cheese helps lubricate the bowels.

C. You do need to continue your iron pills.

D. Add extra fiber, which can be found in fruit.

ANS: B

Cheese tends to cause constipation, so this statement by the student needs correction by

the nurse. The other statements are all correct.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

The nurse is caring for a patient whose English is limited. When the nurse provides

information, the patient smiles and nods her head. What action by the patient indicates that

the goal for a primary nursing diagnosis for this patient has been met?

A. Keeps next appointment and brings a translator with her.

B. Gains an appropriate amount of weight at next visit.

C. Husband accompanies patient to appointments.

D. Continues to eat culturally appropriate foods

ANS: A

The primary goal for this situation is Impaired Verbal Communication due to lack of English

proficiency. If the patient is able to understand and keep her next appointment and brings a

translator with her to help facilitate communication that shows that the goal of adequate

communication has been met. The other actions do not address communication.

PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating

REF: p. 246 OBJ: Nursing Process: Evaluation

The nurse in the OB triage area has four patients to see. Which patient should the nurse see

first?

a. First trimester, vomiting for an hour

b. Second trimester, fingers swollen

c. Third trimester, painful urination

d. Third trimester, painful vaginal bleeding

ANS: D

This patient may have a placenta previa or abruptio placentae or might be having a

spontaneous abortion. The nurse needs to see this patient first. The other patients may have

normal vomiting of the first trimester. Swollen fingers indicate edema that needs to be

investigated. Painful urination probably indicates a urinary tract infection. The priority

patient is the one with bleeding.

PTS: 1 DIF: Cognitive Level: Analysis/Analyzing

REF: Safety Alert Box OBJ: Nursing Process: Asses

The nurse is caring for a woman who had infibulation performed on her as a child. Which of

the following actions by the perinatal nursing staff are appropriate for this patient? (Select

all that apply.)

a. Obtaining frequent urinalysis collections

b. Providing larger equipment for exams

c. Astute assessments for pain during procedures

d. Monitoring for infections

e. Draping the woman maximally

ANS: A, C, D, E

Female genital mutilation, cutting, or circumcision, also called infibulation, involves removal

of some or all of the external female genitalia. The labia majora are often stitched together

over the vaginal and urethral opening as part of this practice. The woman is at risk for many

issues including urinary tract and other genital infections and pain. Often the woman will not

give any verbal or nonverbal signs of pain so the nurse must be astute in assessing for it.

Draping the woman should be done as completely as possible. The equipment for exams

must be smaller, such as a pediatric speculum.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 246 OBJ: Integrated Process: Culture and Spirituali

A pregnant woman reports that she works in a long-term care setting and is concerned about

the impending flu season. She asks about receiving the flu vaccine. Which vaccines could this

patient receive? (Select all that apply.)

a. Tetanus

b. Hepatitis A and B

c. Measles, mumps, rubella (MMR)

d. Influenza

e. Varicella

ANS: A, B, D

Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe

to administer for women who have a risk for contracting or developing the disease.

Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox

are contraindicated during pregnancy because of the possible teratogenic effects on the fetus.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 235 OBJ: Nursing Process: Implementation

During pregnancy there are a number of changes that occur as a direct result of the presence of

the fetus. Which of these adaptations meet these criteria? (Select all that apply.)

a. Leukorrhea

b. Development of a mucous plug

c. Quickening

d. Ballottement

e. Lightening

ANS: A, C, E

Leukorrhea is a white or slightly gray vaginal discharge that develops in response to cervical

stimulation by estrogen and progesterone. Quickening is the first recognition of fetal

movements, or "feeling life." Quickening is often described as a flutter and is felt earlier in

multiparous women than in primiparas. Lightening occurs when the fetus begins to descent

into the pelvis. This occurs 2 weeks before labor in the nullipara and at the start of labor in

the multipara. Mucus fills the cervical canal, creating a plug that acts as a barrier against

bacterial invasion during pregnancy. Passive movement of the unengaged fetus is referred to

as ballottement.

PTS: 1 DIF: Cognitive Level: Comprehension/Understandin

A pregnant woman asks the nursing student what to do about her frequent heartburn. What

suggestions can the student make that are appropriate? (Select all that apply.)

a. Try chewing gum during the day.

b. Take Alka-Seltzer or other antacid.

c. Drink a small sip of cream before meals.

d. Eat small amounts of dry crackers.

e. Wear loose-fitting clothing.

ANS: A, C, E

Chewing gum, a small sip of cream before meals, and wearing loose clothing all can

help relieve heartburn. The patient can take antacids recommended by the provider, but

Alka-Seltzer has too much sodium. Dry crackers help with morning sickness.

PTS: 1 DIF: Cognitive Level: Comprehension/Understandi