Preview Extract
Chapter 11
1) The nurse is preparing a class for expectant fathers. Which information should the nurse
include?
1. Siblings adjust readily to the new baby.
2. Sexual activity is safe for normal pregnancy.
3. The expectant mother decides the feeding method.
4. Fathers are expected to be involved in labor and birth.
Answer: 2
Rationale 1:
Siblings often have difficulty adapting to the arrival of a new baby. Regression is often seen
in siblings’ behaviors.
Rationale 2:
During a normal pregnancy, sexual activity is safe for both mother and baby.
Rationale 3:
Often, the father wants input into the feeding method.
Rationale 4:
In some cultures, labor and birth are only for women, and it is inappropriate for fathers to be
involved with the labor and birth.
2) The nurse is caring for a pregnant patient. The patient’s husband has come to the prenatal
visit. Which question is best for the nurse to use to assess the adaptation to pregnancy by the
father-to-be?
1. “What kind of work do you do?”
2. “What furniture have you gotten for the baby?”
3. “How moody has your wife been lately?”
4. “How are you feeling about becoming a father?”
Answer: 4
Rationale 1:
What kind of work the husband does is not an indicator of his adaptation.
Rationale 2:
What furniture has been obtained is not an indicator of his adaptation.
Rationale 3:
The husband’s perception of his wife’s moodiness is not an indicator of his adaptation.
Rationale 4:
The adaptation of a husband to pregnancy includes his feelings about impending fatherhood.
3) The nurse is caring for a patient in the prenatal clinic. The patient recently arrived in the
United States as a refugee from a country in Africa. This is the first patient from this cultural
background with whom the nurse has worked. Which intervention is most appropriate in the
care of this patient?
1. Ask the patient about her expectations during the labor and birth.
2. Determine if the patient has been tested for tuberculosis.
3. Help the patient into the paper dressing gown prior to her exam.
4. Look for written handouts on prenatal care in the patient’s language.
Answer:
Rationale 1:
Women new to the U.S. will have little or no experience with the U.S. health care system.
Culture heavily influences a patient’s behaviors and attitudes during pregnancy, labor, and
birth, so determining what the patient wants during her labor and birth will facilitate both a
better experience for the family and a calmer situation for the health care team.
Rationale 2:
Although tuberculosis is pandemic in refugee camps, and testing for tuberculosis in new
arrivals to the U.S. is important, this question is about prenatal care. Testing for tuberculosis
is not related to prenatal care.
Rationale 3:
The patient is probably unfamiliar with paper dressing gowns and will need some instruction
(often through demonstration). But this is not the highest priority. It is more important to find
out what the patient expects to happen during her labor and birth.
Rationale 4:
Providing written handouts in the patient’s primary language is important. But a higher
priority for prenatal care would be to assess what the patient’s expectations for labor and
birth are.
4) A Hispanic American patient who is 26 weeks pregnant asks if her curandero, or folk
healer, may accompany her to all future prenatal appointments. Which response by the nurse
reflects respect for the patient's cultural beliefs?
1. "Yes, we will work as a team as much as possible in taking care of you."
2. "National law prohibits the inclusion of anyone who is unlicensed to practice health care
from giving health-related advice."
3. "Because of the risks to your baby, we do not recommend that patients use alternative
healthcare methods."
4. "We prefer that only the father of the baby and your relatives accompany you to your
prenatal visits."
Answer: 1
Rationale 1:
During pregnancy and birth, cultural and spiritual practices, including alternative healers and
caregivers, should be incorporated into prenatal care as much as possible.
Rationale 2:
While certain disciplines require licensure and certification, numerous complementary and
alternative healers provide health-related advice.
Rationale 3:
Cultural competence includes incorporating the patient's cultural and spiritual beliefs into her
care, while evaluating the potential negative health consequences of her healthcare beliefs.
Rationale 4:
The patient is free to choose who accompanies her during prenatal visits.
5) A Chinese woman who is 16 weeks pregnant reports to the nurse that ginseng and bamboo
leaves help to reduce her anxiety. How should the nurse respond to this patient?
1. Advise the patient to avoid the use of all herbs.
2. Assess the amount and frequency with which the patient is using the remedy.
3. Tell the patient that her remedies have no scientific foundation.
4. Assess where the patient obtains her remedy, and investigate the source.
Answer: 2
Rationale 1:
Because some herbs have negative effects on pregnancy, using a reliable reference to
determine the actions of the herbs can educate both the nurse and the patient.
Rationale 2:
Use of herbs is a common alternative healthcare practice for many women. Pregnant women
are often taught “secret family recipes” for avoiding or minimizing the discomforts of
pregnancy. It is appropriate to assess the amount and frequency of the patient’s use of the
herbs.
Rationale 3:
Some remedies do have scientific foundation, so it is not appropriate to instruct the patient
that none do.
Rationale 4:
It is outside the nurse’s scope to assess the source of the herbs.
6) The nurse is teaching an early pregnancy class for patients in the first trimester of
pregnancy. Which statement requires immediate intervention by the nurse?
1. “When my nausea is bad, I will drink some ginger tea.”
2. “The fatigue I am experiencing will improve in the second trimester.”
3. “It is normal for my vaginal discharge to get green-colored.”
4. “I will urinate less often during the middle of my pregnancy.”
Answer: 3
Rationale 1:
Ginger helps nausea, and is safe for use during pregnancy.
Rationale 2:
First-trimester fatigue is common; fatigue usually improves during the second trimester.
Rationale 3:
Leukorrhea is an increase in white vaginal discharge and is an expected finding during
pregnancy. Green discharge is not a normal finding and indicates a bacterial infection. The
infection can be a sexually transmitted infection or bacterial vaginosis. Further assessment is
required for a patient with green vaginal discharge.
Rationale 4:
As the uterus rises in the pelvis during the second trimester, urinary frequency decreases.
Urinary frequency increases again during the end of the third trimester as the fetal head
descends into the pelvis.
7) A patient who is at 10 weeks' gestation tells her nurse, "I'm making too much saliva, and I
spit on people every time I talk! What's wrong with me?" How should the nurse respond?
1. "Let's schedule you for a doctor's appointment, because excessive salivation can signal a
complication of pregnancy."
2. "That's called ptyalism, and it's usually caused by increased salt intake during the second
trimester."
3. "You should avoid astringent mouthwashes and chewing gum."
4. "Excess salivation commonly occurs during the first trimester, although the cause is
unknown."
Answer: 4
Rationale 1:
Excess salivation, also called ptyalism, is a normal occurrence in women during the first
trimester.
Rationale 2:
Ptyalism, which is excess production of saliva, usually occurs during the first trimester and
the cause is unknown.
Rationale 3:
Astringent mouthwashes, chewing gum, and sucking hard candy may help relieve the bitter
taste that often accompanies ptyalism.
Rationale 4:
Ptyalism, which is excess production of saliva, commonly occurs during the first trimester
and the cause is unknown.
8) Upon arriving at the prenatal clinic in the morning, the nurse receives messages from four
patients. Which patient complaint should be addressed first?
1. Primip at 9 weeks' gestation with increased fatigue and nocturia
2. Multip at 30 weeks' gestation with vaginal bleeding after performing yoga
3. Primip at 24 weeks' gestation with ankle edema
4. Multip at 35 weeks' gestation with new onset of hemorrhoids
Answer: 2
Rationale 1:
Fatigue and increased urination at night is a common pregnancy-related discomfort during the
first trimester.
Rationale 2:
Vaginal bleeding after yoga is a warning sign that should be immediately reported to the
primary care provider; this patient is the highest priority for care.
Rationale 3:
Particularly during the second and third trimester, ankle edema is a common pregnancyrelated discomfort.
Rationale 4:
Hemorrhoids are a common pregnancy-related discomfort, especially during the second and
third trimester.
9) A 32-year-old primipara who is 8 weeks' gestation asks you if she should expect any
respiratory changes as her pregnancy progresses. What should the nurse tell her?
1. "By the third trimester, you will no longer feel as though you’re short of breath.”
2. "If you develop shortness of breath, it should improve in the last few weeks of your
pregnancy, as lightening occurs."
3. "Shortness of breath is an abnormal finding during any stage of pregnancy, and it's
considered a serious complication."
4. "You may experience shortness of breath due to stretching of the round ligament."
Answer: 2
Rationale 1:
Shortness of breath occurs as the uterus rises into the abdomen and causes pressure on the
diaphragm. This problem worsens in the last trimester.
Rationale 2:
The primigravida experiences considerable relief from shortness of breath in the last few
weeks of pregnancy, when lightening occurs and the fetus and uterus move down in the
pelvis.
Rationale 3:
Because of decreased vital capacity from pressure of the enlarging uterus on the diaphragm,
shortness of breath is a common problem of pregnancy.
Rationale 4:
Round ligament stretching causes a “grabbing” sensation in the lower abdomen and inguinal
area.
10) The patient in her first trimester of pregnancy is experiencing nausea. To promote selfcare, the nurse should help the pregnant patient understand that the nausea might be relieved
by:
1. Eating spicy foods.
2. Not eating until two hours after rising.
3. Eating small, frequent meals.
4. Avoiding carbonated beverages.
Answer: 3
Rationale 1:
The nausea of pregnancy can be exacerbated by ketosis, fatigue, and certain foods, such as
those containing caffeine or spices.
Rationale 2:
Eating dry carbohydrates prior to rising each day can help to prevent or decrease the severity
of the nausea.
Rationale 3:
Avoiding severe hunger by eating small, frequent meals throughout the day can help to
prevent or decrease the severity of the nausea.
Rationale 4:
Carbonated beverages might be helpful in decreasing nausea.
11) A patient in her third trimester of pregnancy reports frequent leg cramps. What strategy
would be most appropriate for the nurse to suggest?
1. Point the toes of the affected leg.
2. Increase intake of protein-rich foods.
3. Limit activity for several days.
4. Flex the foot to stretch the calf.
Answer: 4
Rationale 1:
Pointing the toes will exacerbate leg cramps.
Rationale 2:
Protein intake does not affect leg cramps.
Rationale 3:
Limiting activity is not appropriate.
Rationale 4:
Leg cramps are a common problem in pregnancy, resulting from an imbalance in the
calcium–phosphorus ratio; pressure on nerves or decreased circulation in the legs from the
enlarged uterus; or fatigue. Dorsiflexing the foot will stretch the calf muscles and will help
relieve the cramps.
12) The prenatal patient in her third trimester tells the clinic nurse that she works eight hours
a day as a cashier and stands when at work. What response by the nurse is best?
1. “No problem. Your baby will be fine.”
2. “Do you get regular breaks for eating?”
3. “Your risk of preterm labor is higher.”
4. “Standing might increase ankle swelling.”
Answer: 3
Rationale 1:
Standing more than five hours a day increases the risk of preterm labor. To be therapeutic in
communication, avoid false reassurance.
Rationale 2:
Although breaks for eating, drinking, and toileting are important for pregnant employees, it is
more important to tell the patient about the increased risk of preterm labor.
Rationale 3:
Pregnant women who stand for more than five a day have an increased risk of preterm labor.
Because preterm labor can put the infant’s life at risk, this statement would be the highest
priority.
Rationale 4:
Although this is true, it is less important than teaching the patient about the risks of preterm
labor when standing more than five hours a day.
13) The pregnant patient has asked the nurse what kinds of medications cause birth defects.
Which statement would best answer this question?
1. “Birth defects are very rare. Don’t worry; your doctor will watch for problems.”
2. “To be safe, don’t take any medication without talking to your doctor.”
3. “Too much vitamin C is one of the most common issues but is avoidable.”
4. “Almost all medications will cause birth defects in the first trimester.”
Answer: 2
Rationale 1:
The nurse should avoid a “don’t worry” answer to ensure therapeutic communication, but it is
appropriate to instruct the patient to talk to the doctor about medications.
Rationale 2:
Teratogens are substances that can cause birth defects. Alcohol is one example, as are
warfarin (Coumadin) and isotretinoin (Roaccutane). The greatest risk is during the first
trimester, but not all medications are teratogenic. Those medications with clear evidence of
teratogenicity are classified in pregnancy category X and should be avoided when conception
is being attempted and during the first trimester.
Rationale 3:
Vitamin C can cause rebound scurvy but is not teratogenic.
Rationale 4:
Not all medications are teratogenic.
14) A pregnant patient who swims 3–5 times per week asks the nurse if she should stop this
activity. What is the appropriate nursing response?
1. “You should decrease the number of times you swim per week.”
2. “You should continue your exercise program because it would be beneficial.”
3. “You should discontinue your exercise program immediately.”
4. “You should increase the number of times you swim per week.”
Answer: 2
Rationale 1:
Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but
even mild exercise is helpful. Women who exercise regularly have better muscle tone, selfimage, bowel function, energy levels, sleep, and postpartum recovery than do those who are
sedentary.
Rationale 2:
Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but
even mild exercise is helpful. Women who exercise regularly have better muscle tone, selfimage, bowel function, energy levels, sleep, and postpartum recovery than do those who are
sedentary.
Rationale 3:
Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but
even mild exercise is helpful. Women who exercise regularly have better muscle tone, selfimage, bowel function, energy levels, sleep, and postpartum recovery than do those who are
sedentary.
Rationale 4:
Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but
even mild exercise is helpful. Women who exercise regularly have better muscle tone, selfimage, bowel function, energy levels, sleep, and postpartum recovery than do those who are
sedentary.
15) The pregnant patient is in her 21st week of pregnancy and is planning a vacation with her
family. She asks the nurse which method of travel would be recommended for her to use.
How should the nurse respond? “The safest method of travel is to:
1. “Take an automobile.”
2. “Fly on an airplane.”
3. “Travel by train.”
4. “Not travel this late in pregnancy.”
Answer: 3
Rationale 1:
Automobile travel does not allow for frequent enough movement.
Rationale 2:
Airplane travel does not allow for frequent enough movement.
Rationale 3:
In the latter half of pregnancy, frequent movement is recommended for pregnant women,
both to increase comfort and to decrease venous pooling, which can lead to thrombophlebitis.
The train allows the most movement for the traveling pregnant woman.
Rationale 4:
It is not necessary to cease travel altogether.
16) The nurse is explaining the importance of fetal activity assessment to the patient. What
should the nurse do to best reinforce the significance of fetal kick counting to the patient?
1. Perform daily phone calls to the patient at work or home.
2. Review the patient’s written record of fetal movement at each visit.
3. Ask the patient to remember to count the fetal movements.
4. Explain the rationale for counting fetal movement to the patient.
Answer: 2
Rationale 1:
Daily phone calls would take emphasis away from the importance of the patient’s counting of
fetal movement.
Rationale 2:
Patients should be instructed to begin counting fetal movement between 24 and 28 weeks. A
fetus that has been active and has a sudden decrease in movements could be conserving
energy due to hypoxia. Movements are counted in a specified time period, such as for one
hour after each meal, or beginning with arising in the morning.
Rationale 3:
Writing down the count is more accurate than the patient’s simply remembering. When the
nurse examines the written record the patient has kept, it reinforces the importance of the
record and improves the likelihood of continued record keeping.
Rationale 4:
Knowing the reasons for the counting will increase understanding of the process but will not
reinforce its significance of the task.
17) A 23-year-old patient is 10 weeks' gestation with her first pregnancy. She expresses
worry over feeling no sexual desire for her husband and asks if this is normal. How should
the nurse respond?
1. "That sounds normal. In many cases, sexual desire decreases in the first trimester, but it
increases again during the second trimester."
2. "That's unusual. Usually, there are minimal changes in sexual desire throughout a healthy
pregnancy."
3. "That sounds normal. During the first trimester, sexual desire often decreases; however, by
the third trimester, sexual desire is usually greater than before pregnancy."
4. "That's unusual. Throughout a healthy pregnancy, sexual desire usually increases with each
trimester."
Answer: 1
Rationale 1:
During the first trimester, factors such as fatigue, nausea, vomiting, and breast tenderness
may decrease desire for sexual activity. During the second trimester, as these discomforts
lessen and pelvic vascular congestion increases, the woman may experience greater sexual
satisfaction than before pregnancy.
Rationale 2:
While each woman may be different, sexual desire often decreases during the first trimester,
increases during the second trimester, and then decreases again during the third trimester.
Rationale 3:
While each woman may be different, sexual desire often decreases during the first trimester,
increases during the second trimester, and then decreases again during the third trimester.
Rationale 4:
While each woman may be different, sexual desire often decreases during the first trimester,
increases during the second trimester, and then decreases again during the third trimester.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
