Preview Extract
Chapter 14
1) The nurse is responding to phone calls. Which call should the nurse return first?
1. 37 weeks’ gestation, reports no fetal movement for 24 hours
2. 29 weeks’ gestation, reports increased fetal movement.
3. 32 weeks’ gestation, reports decreased fetal movement for 2 days
4. 35 weeks’ gestation, reports decreased fetal movement for 4 hours
Answer: 1
Rationale 1:
A lack of fetal movement in a fetus in the third trimester can indicate fetal hypoxia or fetal
death. This patient is the highest priority.
Rationale 2:
Increased fetal movement is not indicative of a problem.
Rationale 3:
Although decreased fetal movement can indicate intrauterine growth restriction or fetal
hypoxia, this patient is not the highest priority.
Rationale 4:
Although decreased fetal movement can indicate intrauterine growth restriction or fetal
hypoxia, four hours is a very short amount of time to assess decreased fetal movement.
2) A woman at 28 weeks’ gestation is asked to keep a fetal activity diary and to bring the
results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells
the nurse that she has not felt the baby move for over 30 minutes. The most appropriate initial
comment by the nurse would be:
1. “You need to come to the clinic right away for further evaluation.”
2. “Have you been smoking?”
3. “When did you eat last?”
4. “Your baby might be asleep.”
Answer: 4
Rationale 1:
The mother would need to come to the clinic only if there had been no fetal activity for
several hours.
Rationale 2:
Smoking typically will stimulate the infant.
Rationale 3:
After meals, an infant typically is active and moving.
Rationale 4:
Lack of fetal activity for 30 minutes typically is insignificant and means only that the infant is
sleeping. If the mother truly is concerned, in 30 minutes, she could eat a complexcarbohydrate snack. This would stimulate the infant, and the mother should have fetal
activity. But at present, this is an indicator the infant is sleeping.
3) The nurse is preparing a patient in her second trimester for a three-dimensional ultrasound
examination. Which statement indicates that teaching had been effective?
1. “If the ultrasound is normal, it means my baby has no abnormalities.”
2. “The nuchal translucency measurement will diagnose Down syndrome.”
3. “I might be able to see who the baby looks like with the ultrasound.”
4. “Measuring the length of my cervix will determine if I will deliver early.”
Answer: 3
Rationale 1:
Not all fetal anomalies are detectable by ultrasound.
Rationale 2:
Nuchal translucency measurements are screening, not diagnostic, for trisomies 13, 18, and
21.
Rationale 3:
Ultrasounds provide a very clear photo-like image of the fetus, often providing parents the
opportunity to identify a familial characteristic such as nose shape.
Rationale 4:
Transvaginal ultrasound is used to measure the cervical length as a screening for risk of
preterm labor. However, a normal-length cervix does not preclude preterm birth.
4) A woman is at 32 weeks’ gestation. Her fundal height measurement at this clinic
appointment is 26 centimeters. After reviewing her ultrasound results, the healthcare provider
asks the nurse to schedule the patient for a series of sonograms to be done every two weeks.
The nurse should make sure that the patient understands that the main purpose for this is to:
1. Assess for congenital anomalies.
2. Evaluate fetal growth.
3. Determine fetal presentation.
4. Rule out a suspected hydatidiform mole.
Answer: 2
Rationale 1:
Assessment of anomalies would require only one ultrasound.
Rationale 2:
A person who is at 32 weeks’ gestation should measure 32 cm of fundal height. When a
discrepancy between fundal height and measurement exists, the purpose of serial ultrasounds
is to monitor fetal growth.
Rationale 3:
Fetal presentation would require only one ultrasound.
Rationale 4:
Ruling out a hydatidiform mole would require only one ultrasound.
5) In assisting with an abdominal ultrasound procedure for determination of fetal age, the
nurse:
1. Asks the woman to sign an operative consent form prior to the procedure.
2. Has the woman empty her bladder before the test begins.
3. Assists the woman into a supine position on the examining table.
4. Instructs the woman to eat a fat-free meal two hours before the scheduled test time.
Answer: 3
Rationale 1:
Abdominal ultrasounds are not invasive procedures and do not require a consent form.
Rationale 2:
The recommendation is that the patient should have a full bladder to help elevate the uterus
out of the pelvic cavity for better visualization.
Rationale 3:
Patients are placed in a supine position on the table.
Rationale 4:
Dietary intake is not relevant to the ultrasound.
6) The prenatal clinic nurse is responding to a patient who has had an assessment for fetal
well-being. Which statement indicates that the patient understands the test result?
1. “The normal Doppler velocimetry wave result indicates my placenta is getting enough
blood to the baby.”
2. “The reactive nonstress test means that my baby is not growing because of a lack of
oxygen.”
3. “Because my contraction stress test was positive, we know that my baby will tolerate labor
well.”
4. “My biophysical profile score of 6 points indicates everything being normal and healthy
for my baby.”
Answer: 1
Rationale 1:
The Doppler velocimetry test looks at blood flow through the umbilical artery. A normal
result indicates there is no vasospasm decreasing blood flow to the placenta; therefore, the
baby is getting an adequate blood supply.
Rationale 2:
The nonstress test utilizes external fetal monitoring to assess the fetal heart rate in
relationship to fetal movement. When accelerations in the fetal heart rate are associated with
fetal movement (a reactive result), the fetus is well oxygenated, and the placenta is
functioning well.
Rationale 3:
A contraction stress test creates mild contractions. The presence of decelerations is termed a
positive result and indicates a lack of adequate placental functioning.
Rationale 4:
The biophysical profile score should be 8 (with adequate amniotic fluid) or 10. A score of 6 is
abnormal and indicates that further assessment is needed.
7) At 32 weeks’ gestation, a woman is scheduled for a second nonstress test (following the
one she had at 28 weeks’ gestation). Which response by the patient would indicate an
adequate understanding of this procedure?
1. “I can’t get up and walk around during the test.”
2. “I’ll have an IV started before the test.”
3. “I must avoid drinks containing caffeine for 24 hours before the test.”
4. “I need to have a full bladder for this test.”
Answer: 1
Rationale 1:
The purpose of the nonstress test is to determine the results of movement on fetal heart rate.
The patient will have to lie still on her side during the procedure.
Rationale 2:
There is no IV needed to administer medications.
Rationale 3:
Caffeine might cause the infant to be more active and cause the test to go more quickly.
Rationale 4:
Patients usually are asked to have their bladders full only for ultrasounds.
8) During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats
during a period of fetal movement. The decelerations occur twice during the test and last 20
seconds each. The nurse realizes these results will be interpreted as:
1. A negative test.
2. A reactive test.
3. A non-reactive test.
4. An equivocal test
Answer: 3
Rationale 1:
Nonstress tests are scored as either reactive or non-reactive.
Rationale 2:
A reactive stress test has the expected results of an increase in heart rate of 15 beats per
minute for 15 seconds or more.
Rationale 3:
In a non-reactive stress test, the reactivity criteria are not met. Since this patient experienced
a deceleration during the test, this is considered non-reactive.
Rationale 4:
Nonstress tests are scored as either reactive or non-reactive.
9) A pregnant woman is having a nipple-stimulated contraction stress test. Which result
indicates hyperstimulation?
1. The fetal heart rate decelerates when three contractions occur within a 10-minute period.
2. The fetal heart rate accelerates when contractions last up to 60 seconds.
3. There are more than five fetal movements in a 10-minute period.
4. There are more than three uterine contractions in a 6-minute period.
Answer: 4
Rationale 1:
Decelerations are considered a positive contraction stress test.
Rationale 2:
The acceleration of the heart rate is considered a negative contraction stress test.
Rationale 3:
The fetal movement is considered a negative contraction stress test.
Rationale 4:
Hyperstimulation is characterized by contractions closer than or equal to every 6 minutes or
lasting longer than 90 seconds.
10) Of all the patients who have been scheduled to have a biophysical profile, for which
patient should the nurse clarify the physician’s order?
1. A gravida with intrauterine growth restriction
2. A gravida with mild hypertension of pregnancy
3. A gravida who is post-term
4. A gravida who complains of decreased fetal movement for 2 days
Answer: 2
Rationale 1:
The infant who has intrauterine growth problems might be compromised due to placental
insufficiency.
Rationale 2:
The biophysical profile is used when there is a risk of placental and/or fetal compromise. The
gravida with mild hypertension will need to be monitored more closely throughout the
pregnancy but is not a candidate at present for a biophysical profile.
Rationale 3:
The infant who is post-term might be compromised due to placental insufficiency.
Rationale 4:
The gravida who is experiencing decreased fetal movement for 2 days needs assessment of
the placenta and the fetus.
11) The nurse is reviewing nursing documentation related to the care of a patient who had an
amniocentesis. Which nursing notes reflect appropriate patient care?
1. An Rh-positive patient received RhoGAM after the amniocentesis.
2. The patient was monitored for 30 minutes after completion of the test.
3. Prior to discharge, the patient demonstrated vaginal spotting.
4. The patient reported that she takes insulin before each meal and at bedtime.
Answer: 2
Rationale 1:
Only Rh-negative patients receive RhoGAM after amniocentesis. The Rh-positive patient
should not ever receive RhoGAM.
Rationale 2:
Twenty to thirty minutes of fetal monitoring is performed to assess for fetal well-being and to
rule out injury of the fetus or placenta during the exam.
Rationale 3:
Vaginal spotting after the amniocentesis is not an expected finding. A patient experiencing
vaginal bleeding of any amount after amniocentesis requires additional assessment and
should not be sent home.
Rationale 4:
Whether or not a patient takes insulin has nothing to do with amniocentesis. This answer does
not relate to the question asked.
12) Each of the following pregnant women is scheduled for a 14-week antepartum visit. In
planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein
(AFP) screening to which patient?
1. 28-year-old with history of rheumatic heart disease
2. 18-year-old with exposure to HIV
3. 20-year-old with a history of preterm labor
4. 35-year-old with a child with spina bifida
Answer: 4
Rationale 1:
The patient with rheumatic heart disease would need to be monitored for pregnancy and the
stressors it places on the patient.
Rationale 2:
The patient with HIV exposure needs HIV testing and protection education.
Rationale 3:
The patient with a history of preterm labor needs education on prevention and signs and
symptoms of preterm labor.
Rationale 4:
Alpha-fetoprotein (AFP) is elevated in multigestational pregnancies and in pregnancies with
neural tube defects such as spina bifida and Down syndrome. The 35-year-old is considered
to be of advanced maternal age and is at risk for having a child with Down syndrome, and
with the past history of a child with spina bifida, would be highly encouraged to have the
AFP screening.
13) The nurse is creating a patient education brochure describing amniocentesis. Which
statement is most important for the nurse to include in the brochure?
1. “Prior to the amniocentesis, you will be asked to sign a consent form.”
2. “After the amniocentesis, your vital signs will be monitored.”
3. “During the amniocentesis, you might experience leaking of fluid.”
4. “Following the amniocentesis, you can return to normal activities.”
Answer: 2
Rationale 1:
This is a true statement, but direct patient care, including monitoring for complications, is a
higher priority.
Rationale 2:
Vital signs are monitored and fetal monitoring is performed after amniocentesis to verify that
both mother and fetus are physiologically stable after the test is completed.
Rationale 3:
Leaking of fluid is a complication of amniocentesis indicating rupture of membranes.
Rationale 4:
Activity should be restricted for 24 hours after the amniocentesis to help prevent
complications.
14) A woman who is 12 weeks' gestation asks the nurse if she can undergo chorionic villus
sampling (CVS) testing in order to determine whether her baby has a neural tube defect.
Which response is best?
1. "Yes, at 12 weeks' gestation, CVS can be used to diagnose a neural tube defect."
2. "No, because CVS testing is not performed until after 20 weeks' gestation."
3. "Yes, at 12 weeks' gestation, CVS is combined with amniocentesis to diagnose neural tube
defects."
4. "No, because CVS testing alone at any stage cannot detect neural tube defects."
Answer: 4
Rationale 1:
CVS is typically performed between 10 and 13 weeks' gestation; however, CVS does not
detect neural tube defects.
Rationale 2:
While CVS is typically performed between 10 and 13 weeks' gestation, this test cannot detect
neural tube defects.
Rationale 3:
CVS is typically performed between 10 and 13 weeks' gestation; however, amniocentesis is
not performed until 15 weeks' gestation.
Rationale 4:
While CVS is typically performed between 10 and 13 weeks' gestation, this test cannot detect
neural tube defects.
15) A woman who is 15 weeks' gestation received normal chorionic villus sampling (CVS)
results and abnormal quadruple screen test results. For detection of congenital anomalies,
which test should the nurse expect the woman to be offered next?
1. Amniocentesis
2. Ultrasound
3. Contraction Stress Test (CST)
4. Nonstress test (NST)
Answer: 1
Rationale 1:
Women who have a normal CVS and an abnormal quadruple screen test would be offered
amniocentesis to screen for congenital anomalies.
Rationale 2:
While ultrasound has many uses, is not useful in the diagnosis of congenital anomalies.
Rationale 3:
The contraction stress test is used to assess fetal status.
Rationale 4:
The nonstress test is used to assess fetal status.
16) Prior to performing amniocentesis, which nursing action is appropriate?
1. Administering Rh immune globulin to a woman who is Rh-negative
2. Prepping the abdominal skin with povidone-iodine (Betadine)
3. Assisting the woman with assuming a right lateral position
4. Providing non-sterile gloves for use by the physician performing the procedure
Answer: 2
Rationale 1:
Rh immune globulin is administered prophylactically following an amniocentesis to prevent
Rh sensitization in an Rh-negative woman.
Rationale 2:
Prior to amniocentesis, current guidelines recommend prepping the abdominal skin with
povidone-iodine (Betadine).
Rationale 3:
The woman should be positioned supine for amniocentesis.
Rationale 4:
When performing amniocentesis, sterile gloves are worn by the physician.
17) The nurse is assisting a nurse-midwife with performing a contraction stress test (CST) on
a patient who is 30 weeks' gestation. The monitor reveals a hypersystole pattern. What order
should the nurse expect to receive from the physician?
1. Change the patient's position to Trendelenburg.
2. Assist the patient with application of an electric breast pump.
3. Obtain a 15-minute recording of uterine activity.
4. Administer a tocolytic medication.
Answer: 4
Rationale 1:
The patient is demonstrating hypersystole pattern of uterine contraction and would most
likely receive a tocolytic medication.
Rationale 2:
Breast stimulation may be used to produce uterine contractions during CST.
Rationale 3:
While monitoring is appropriate, a hypersystole pattern of uterine contractions requires
pharmacologic treatment with a tocolytic agent.
Rationale 4:
During CST, development of a hypersystole pattern requires prompt administration of a
tocolytic agent.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
