Maternal Newborn Nursing The Critical Components Of Nursing Care 2nd Edition by Roberta Durham – Test Bank

Maternal Newborn Nursing The Critical Components Of Nursing Care 2nd Edition by Roberta Durham – Test Bank

Chapter 7: High-Risk Antepartum Nursing Care

Multiple Choice

1. A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure client safety.a. Assess uterine contractions continuously.b. Assess fetal heart rate continuously.c. Assess urinary output.d. Assess respiratory rate.

ANS: d
Feedback
a. Monitoring contractions does not indicate magnesium toxicity.
b. Magnesium sulfate will decrease fetal variability and not provide an accurate assessment of magnesium toxicity.
c. Urinary output does not correlate to decreased deep tendon reflexes.
d. Correct. Respiratory effort and deep tendon reflexes (DTRs) are involuntary, and a decrease in DTRs could indicate the risk of magnesium sulfate toxicity and the risk for decreased respiratory effort.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate

2. A pregnant client with a history of multiple sexual partners is at highest risk for which of the following complications:a. Premature rupture of membranesb. Gestational diabetesc. Ectopic pregnancyd. Pregnancy-induced hypertension

ANS: c
Feedback
a. Multiple partners do not increase a woman’s risk of premature rupture of membranes.
b. Genetics and client diet and weight are contributing factors to gestational diabetes.
c. Correct. A history of multiple sexual partners places the client at a higher risk of having contracted a sexually transmitted disease that could have ascended the uterus to the fallopian tubes and caused fallopian tube blockage, placing the client at high risk for an ectopic pregnancy.
d. Multiple sexual partners are not a risk factor for pregnancy-induced hypertension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

3. Identify the hallmark of placenta previa that differentiates it from abruptio placenta.a. Sudden onset of painless vaginal bleedingb. Board-like abdomen with severe painc. Sudden onset of bright red vaginal bleedingd. Severe vaginal pain with bright red bleeding

ANS: a
Feedback
a. Correct. When the placenta attaches to the lower uterine segment near or over the cervical os, bleeding may occur without the onset of contractions or pain.
b. The hallmark for abruptio placenta is pain and a board-like abdomen.
c. Bright red bleeding could be related to abruptio placenta, placenta previa, or other complications of pregnancy.
d. Pain is not a hallmark of placenta previa.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

4. Which of the following assessments would indicate instability in the client hospitalized for placenta previa?a. BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPMb. FHR moderate variability without accelerationsc. Dark brown vaginal discharge when voidingd. Oral temperature of 99.9F

ANS: a
Feedback
a. A decrease in BP accompanied by bradycardia or tachycardia is an indication of hypovolemic shock.
b. FHR with moderate variability can be absent of accelerations during fetal sleep cycles or after maternal sedation.
c. Bright red vaginal bleeding is an indication of current bleeding.
d. Oral temperature may fluctuate based on the client’s hydration status. It should be reassessed. Cause for concern is a temperature of 100.4F or more.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

5. During pregnancy, poorly controlled asthma can place the fetus at risk for:a. Hyperglycemiab. IUGRc. Hypoglycemiad. Macrosomia
ANS: b
Feedback
a. Maternal asthma does not place the fetus at risk for hyperglycemia.
b. Compromised pulmonary function can lead to decompensation and hypoxia that decrease oxygen flow to the fetus and can cause intrauterine growth restriction (IUGR).
c. Asthma does not directly affect glycemic control.
d. A fetus experiencing hypoxia would be small for gestational age, not large for gestational age.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: AnalysisContent Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

6. Which of the following nursing diagnoses is of highest priority for a client with an ectopic pregnancy who has developed disseminated intravascular coagulation (DIC)?a. Risk for deficient fluid volumeb. Risk for family process interruptedc. Risk for disturbed identityd. High risk for injury

ANS: a
Feedback
a. Correct. The client is at high risk for hypovolemia which is life threatening and takes precedence over any psychosocial or less pressing diagnoses.
b. This is a psychosocial diagnosis and is not life threatening.
c. This is a psychosocial diagnosis and is not life threatening.
d. The client is at risk for injury; however, the diagnosis of deficient fluid volume is more descriptive and has clearly defined goals and interventions.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult

7. Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension?a. Total urine protein of 200 mg/dLb. Total platelet count of 40,000 mm c. Uric acid level of 8 mg/dLd. Blood urea nitrogen 24 mg/dL

ANS: b
Feedback
a. The client’s urine protein is elevated. A urine protein of ≥300 mg/dL in a 24-hour collection is considered concerning.
b. Correct. A platelet count of 50,000 is a critical value and should be reported to the health-care provider immediately. This client is at increased risk of hemorrhage.
c. The uric acid level is only slightly elevated.
d. The BUN is only slightly elevated.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult

8. Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client’s blood glucose levels?a. Nifedipineb. Betamethasone c. Magnesium sulfated. Indomethacin

ANS: b
Feedback
a. Nifedipine does not affect maternal blood glucose levels.
b. Beta-sympathomimetics may stimulate hyperglycemia which will require an increased need for insulin.
c. Magnesium sulfate does not affect blood glucose levels.
d. Indomethacin does not affect blood glucose levels.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Difficult

9. While educating the client with class II cardiac disease, at 28 weeks’ gestation, the nurse instructs the client to notify the physician if she experiences which of the following conditions? a. Emotional stress at workb. Increased dyspnea while restingc. Mild pedal and ankle edemad. Weight gain of 1 pound in 1 week

ANS: b
Feedback
a. Emotional stress increases cardiac workload; however, without symptoms of cardiac decompensation, this is not immediately concerning.
b. Increasing dyspnea, at rest, can be a sign of cardiac decompensation leading to increased congestive heart failure.
c. Mild edema during the third trimester is normal. However, increasing edema and pitting edema should be reported as they can be a sign of increasing CHF.
d. A weight gain of 1 pound per week is expected during the third trimester.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

10. The nurse working in a prenatal clinic is providing care to three primigravida patients. Which of the patient findings would the nurse highlight for the physician?
a. 15 weeks, denies feeling fetal movement
b. 20 weeks, fundal height at the umbilicus
c. 25 weeks, complains of excess salivation
d. 30 weeks, states that her vision is blurry

ANS: d
Feedback
a. This finding is normal. Quickening is usually felt between 16 and 20 weeks’ gestation.
b. This finding is normal. The fundal height at 20 weeks’ gestation is usually at the level of the umbilicus.
c. Excess salivation is a normal, albeit annoying, finding.
d. Blurred vision is a sign of pregnancy-induced hypertension (PIH). This finding should be reported to the woman’s health-care practitioner.

KEY: Integrated Process: Nursing Process: Implementation | 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: Difficult

11. The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks’ gestation in her first pregnancy. She is worried about having her baby “too soon,” and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be:
a. Preterm labor
b. Term labor
c. Back labor
d. Braxton-Hicks contractions

ANS: d
Feedback
a. Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the end of the 36th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.
b. Term labor occurs after 37 weeks’ gestation.
c. There is no indication in this scenario that this is back labor.
d. Braxton-Hicks contractions are regular contractions occurring after the third month of pregnancy. They may be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

12. The perinatal nurse knows that the term to describe a woman at 26 weeks’ gestation with a history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is:
a. Preeclampsia
b. Chronic hypertension
c. Gestational hypertension
d. Chronic hypertension with superimposed preeclampsia

ANS: d
Feedback
a. Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, and renal and central nervous systems.
b. Chronic hypertension is hypertension that is present and observable prior to pregnancy or hypertension that is diagnosed before the 20th week of gestation.
c. Gestational hypertension is a nonspecific term used to describe the woman who has a blood pressure elevation detected for the first time during pregnancy, without proteinuria.
d. The following criteria are necessary to establish a diagnosis of superimposed preeclampsia: hypertension and no proteinuria early in pregnancy (prior to 20 weeks’ gestation) and new-onset proteinuria, a sudden increase in protein—urinary excretion of 0.3 g protein or more in a 24-hour specimen, or two dipstick test results of 2+ (100 mg/dL), with the values recorded at least 4 hours apart, with no evidence of urinary tract infection; a sudden increase in blood pressure in a woman whose blood pressure has been well controlled; thrombocytopenia (platelet count lower than 100,000/mmC); and an increase in the liver enzymes alanine transaminase (ALT) or aspartate transaminase (AST) to abnormal levels.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

13. A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings?
a. Patellar and biceps reflexes of +4
b. Urinary output of 50 mL/hr
c. Respiratory rate of 10 rpm
d. Serum magnesium level of 5 mg/dL

ANS: c
Feedback
a. The magnesium sulfate has been ordered because the patient has severe pregnancy-induced hypertension. Patellar and biceps reflexes of +4 are symptoms of the disease.
b. The urinary output must be above 25 mL/hr.
c. The drop in respiratory rate may indicate that the patient is suffering from magnesium toxicity. The nurse should report the finding to the physician.
d. The therapeutic range of magnesium is 4 to 7 mg/dL.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Adverse Effects/Contraindications; Antepartum Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Diagnostic Tests | Client Need: Health Promotion and Maintenance; Pharmacological and Parenteral Therapies; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

14. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother?
a. Serum potassium level increases
b. Diarrhea
c. Urticaria
d. Complaints of nervousness

ANS: d
Feedback
a. The nurse would not expect to see a rise in the mother’s serum potassium levels.
b. The beta agonists are not associated with diarrhea.
c. The beta agonists are not associated with urticaria.
d. Complaints of nervousness are commonly made by women receiving subcutaneous beta agonists.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications and Side Effects | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate

15. Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae?
a. Increasing abdominal girth measurements
b. Profuse vaginal bleeding
c. Bradycardia with an aortic thrill
d. Hypothermia with chills

ANS: a
Feedback
a. The nurse would expect to see increasing abdominal girth measurements.
b. Profuse vaginal bleeding is rarely seen in placental abruption and is never seen when the abruption is concealed.
c. With excessive blood loss, the nurse would expect to see tachycardia.
d. The nurse would expect to see a stable temperature.

KEY: Integrated Process: Nursing Process: Assessment | 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

16. A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings?
a. Pyelonephritis
b. Pregnancy-induced hypertension
c. Gestational diabetes
d. Abruptio placentae

ANS: c
Feedback
a. Pyelonephritis does not lead to the development of hydramnios or macrosomia.
b. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia.
c. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies.
d. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult

17. For the patient with which of the following medical problems should the nurse question a physician’s order for beta agonist tocolytics?
a. Type 1 diabetes mellitus
b. Cerebral palsy
c. Myelomeningocele
d. Positive group B streptococci culture

ANS: a
Feedback
a. Beta agonists often elevate serum glucose levels. The nurse should question the order.
b. Beta agonists are not contraindicated for patients with cerebral palsy.
c. Beta agonists are not contraindicated for patients with myelomeningocele.
d. Beta agonists are not contraindicated for patients with group B streptococci.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum 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: Difficult

18. The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption?
a. The patient with placenta previa
b. The patient whose vagina is colonized with group B streptococci
c. The patient who is hepatitis B surface antigen positive
d. The patient with eclampsia

ANS: d
Feedback
a. Patients with placenta previa are not especially high risk for placental abruption.
b. Patients colonized with group B streptococci are not especially high risk for placental abruption.
c. Patients who are hepatitis B surface antigen positive are not especially high risk for placental abruption.
d. Patients with eclampsia are high risk for placental abruption.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Complications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult