Preview Extract
Chapter 15
1) The nurse is caring for a pregnant woman who admits to cocaine and ecstasy use on a
regular basis. The patient states, “Everybody knows that alcohol is bad during pregnancy, but
what’s the big deal about ecstasy?” The best response by the nurse is: “Ecstasy:
1. “Can cause a high fever in you and therefore cause the baby harm.”
2. “Leads to deficiencies of thiamine and folic acid, which help the baby develop.”
3. “Produces babies with small heads and short bodies with brain function alterations.”
4. “Produces intrauterine growth restriction and meconium aspiration.”
Answer: 1
Rationale 1:
High body temperature is a side effect of MDMA (ecstasy). Increased body temperature
increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major
organ damage.
Rationale 2:
Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid. Folic acid helps prevent
neural tube defects.
Rationale 3:
Cocaine causes these fetal effects, not ecstasy.
Rationale 4:
Heroin causes these fetal effects, not ecstasy.
2) The nurse is doing preconception counseling with a 28-year-old woman with no prior
pregnancies. Which of the following statements made by the patient indicates to the nurse
that the patient has understood the teaching?
1. “I can continue to drink alcohol until I am diagnosed as pregnant.”
2. “I need to stop drinking alcohol completely when I start trying to get pregnant.”
3. “A beer once a week will not damage the fetus.”
4. “I can drink alcohol while breastfeeding since it doesn’t pass into breast milk.”
Answer: 2
Rationale 1:
Women should discontinue drinking alcohol when they start to attempt pregnancy.
Rationale 2:
Women should discontinue drinking alcohol when they start to attempt pregnancy.
Rationale 3:
It is not known how much alcohol will cause fetal damage; therefore, alcohol during
pregnancy is contraindicated.
Rationale 4:
Alcohol passes readily into breast milk; therefore, it should be avoided, or the milk should be
pumped and dumped after alcohol consumption.
3) A woman’s history and appearance suggest drug abuse. The nurse’s best approach would
be to:
1. Ask the woman directly, “Do you use any street drugs?”
2. Ask the woman if she would like to talk to a counselor.
3. Ask some questions about over-the-counter medications and avoid the mention of illicit
drugs.
4. Explain how harmful drugs can be for her baby.
Answer: 1
Rationale 1:
The best method of dealing with the patient that the nurse suspects of using drugs is to be
direct and ask the question in a direct fashion without prejudice, bias, or negative body
language. Lack of judgmental attitudes/body language typically results in honest answers.
Rationale 2:
It is the responsibility of the nurse to question the patient.
Rationale 3:
It is the responsibility of the nurse not to avoid the issue.
Rationale 4:
When talking to patients in a therapeutic manner, it is important not to be threatening or
judgmental; an example of the latter behavior would be stating that the drugs will harm the
baby.
4) A 20-year-old woman is at 28 weeks’ gestation. Her prenatal history reveals past drug
abuse, and urine screening indicates that she has recently used heroin. The nurse should
recognize that the woman is at increased risk for:
1. Erythroblastosis fetalis.
2. Diabetes mellitus.
3. Abruptio placentae.
4. Pregnancy-induced hypertension.
Answer: 4
Rationale 1:
Erythroblastosis fetalis is secondary to physiological blood disorders such as Rh
incompatibility.
Rationale 2:
Diabetes is an endocrine disorder that is unrelated to drug use/abuse.
Rationale 3:
Abruptio placentae is seen more commonly with cocaine/crack use.
Rationale 4:
Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced
hypertension (or pre-eclampsia).
5) The patient with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to
become pregnant soon. What anticipatory guidance should the nurse provide this patient?
1. Insulin needs decrease in the first trimester and increase during the third trimester.
2. The risk of ketoacidosis decreases during the length of the pregnancy.
3. Vascular disease that accompanies diabetes slows progression.
4. The baby is likely to have a congenital abnormality because of the diabetes.
Answer: 1
Rationale 1:
In addition, insulin requirements drop suddenly after delivery of the placenta.
Rationale 2:
The risk of ketoacidosis increases during pregnancy.
Rationale 3:
Vascular disease progresses more rapidly during pregnancy, especially if blood sugar control
is not good. Problems such as nephropathy and retinopathy can result.
Rationale 4:
Infants of diabetic mothers have a 5–10% greater risk of having a congenital abnormality.
This risk increases to 20–25% if the HbA1c is over 10%.
6) A newly diagnosed type 1, insulin-dependent diabetic with good blood sugar control is at
20 weeks’ gestation. She asks the nurse how her diabetes will affect her baby. The best
explanation would include:
1. “Your baby may be smaller than average at birth.”
2. “Your baby will probably be larger than average at birth.”
3. “As long as you control your blood sugar, your baby will not be affected at all.”
4. “Your baby might have high blood sugar for several days.”
Answer: 2
Rationale 1:
Poorly controlled type 1 diabetics who have developed vascular problems will have infants
who are small for gestational age (SGA) due to placental insufficiency.
Rationale 2:
The infant of a diabetic mother produces excessive amounts of insulin in response to the high
blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because
the infant utilizes the glucose in the bloodstream.
Rationale 3:
The demands of pregnancy will make it difficult for the best of patients to control blood sugar
on a regular basis.
Rationale 4:
Within minutes of delivery, the baby of an insulin-dependent diabetic can begin to have low
blood sugar.
7) A 26-year-old multigravida is 28 weeks pregnant. She has developed gestational diabetes.
She is following a program of regular exercise, which includes walking, bicycling, and
swimming. What instructions should be included in a teaching plan for this patient?
1. “Exercise either just before meals or wait until two hours after a meal.”
2. “Carry hard candy (or other simple sugar) when exercising.”
3. “If your blood sugar is 120 mg/dl, eat 20 g of carbohydrate.”
4. “If your blood sugar is more than 120 mg/dl, drink a glass of whole milk.”
Answer: 2
Rationale 1:
It is best to exercise just after the meal in order to utilize the glucose.
Rationale 2:
A patient should be encouraged to continue any exercise programs in which she already is
involved. She should keep hard candy (simple sugar) with her at all times, just in case the
exercise induces hypoglycemia.
Rationale 3:
A finger stick result of 120 mg/dl is considered to be normal.
Rationale 4:
Such patients need no additional carbohydrate or protein intake.
8) A 31-year-old woman who is at high risk for diabetes is at 18 weeks' gestation. During her
first antenatal visit, which is the accurate approach to evaluating the patient for diabetes?
1. Begin serial testing of the patient's serum glucose and HA1c at 24 weeks' gestation.
2. If diabetes is diagnosed, consider this condition to be gestational diabetes mellitus (GDM).
3. Recognize HA1c equal to or greater than 4.5% or a fasting plasma glucose level equal to or
greater than 90 mg/dl as being diagnostic of diabetes.
4. Conduct screening for type 2 diabetes mellitus as soon as possible.
Answer: 4
Rationale 1:
Women at high risk for type 2 DM should be screened for diabetes as soon as possible.
Rationale 2:
Women who are determined to have diabetes at this visit should be diagnosed as having overt
diabetes and not GDM.
Rationale 3:
HA1c equal to or greater than 6.5% would be considered diagnostic as would a fasting
plasma glucose level equal to or greater than 126 mg/dl or a 2-hour plasma glucose equal to
or greater than 200 mg/dl during an oral glucose tolerance test (OGTT).
Rationale 4:
Women at high risk for type 2 DM should be screened for diabetes as soon as possible.
9) The pregnant patient at 23 weeks’ gestation has a hemoglobin of 9.5. Which diet choice
indicates that teaching has been effective?
1. Tofu with mixed vegetables in curry, milk, whole-wheat bun
2. Roast beef, steamed spinach, tomato soup, orange juice
3. Pork chop, mashed potatoes and gravy, cauliflower, tea
4. Broiled fish, lettuce salad, grapefruit half, carrot sticks
Answer: 2
Rationale 1:
This diet is high in calcium. The patient has iron-deficiency anemia and requires a high-iron
diet.
Rationale 2:
This patient is anemic and needs iron. This meal contains iron in the beef, folic acid in the
spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of
the iron; folic acid is needed for production of red cells.
Rationale 3:
This meal has a moderate amount of protein, but no vitamin C. The meal containing beef is
better.
Rationale 4:
This meal is high in fiber, low in fat, and moderately high in protein, but low in iron. This
patient is anemic and needs iron.
10) A woman at 30 weeks' gestation and a history including sickle cell anemia presents to the
clinic complaining of fever, chills, and diarrhea for three days. What are the most serious
potential complications faced by this patient?
1. Electrolyte imbalance
2. Sickle cell crisis
3. Fetal neural tube defects
4. Severe lethargy
Answer: 2
Rationale 1:
While the patient may experience electrolyte imbalance, sickle cell crisis is the most serious
potential complication of dehydration and fever.
Rationale 2:
Dehydration and fever can trigger sickling and crisis; for this reason, maternal infections are
treated promptly.
Rationale 3:
Fever, chills, and dehydration in the patient with sickle cell anemia are not associated with an
increased incidence of neural tube defects.
Rationale 4:
While the patient may develop severe lethargy, her greatest risk concerns development of
sickle cell crisis.
11) A patient who is at 18 weeks' gestation has been newly diagnosed with megaloblastic
anemia. Which statement by the patient indicates that she understands the teaching?
1. “I should include fresh leafy green vegetables, red meat, fish, poultry, and legumes in my
diet.”
2. “Whenever possible, I should boil my vegetables in at least 2 quarts of water.”
3. “Megaloblastic anemia is not known to cause any serious risks to my baby.”
4. “My body makes red blood cells that are smaller than they should be."
Answer: 1
Rationale 1:
Folic acid, which is used to treat megaloblastic anemia, is readily available in foods such as
fresh leafy green vegetables, red meat, fish, poultry, and legumes.
Rationale 2:
Folic acid, which is crucial for inclusion in the diet of patients with megaloblastic anemia, is
easily destroyed by overcooking or cooking with large quantities of water.
Rationale 3:
Maternal folic acid deficiency has been associated with an increased risk of neural tube
defects (NTDs) such as spina bifida, meningomyelocele, and anencephaly in the newborn.
Rationale 4:
In megaloblastic anemia, red blood cells become enlarged and are fewer in number.
12) The patient at 9 weeks’ gestation has been told that her HIV test was positive. The patient
is very upset and tells the nurse, “I didn’t know I had HIV! What will this do to my baby?”
The nurse knows teaching has been effective when the patient states:
1. “I cannot take the medications that control HIV during my pregnancy because they will
harm the baby.”
2. “My baby will probably be born with anti-HIV antibodies, but that doesn’t mean it is
infected.”
3. “The pregnancy will increase the progression of my disease and will reduce my CD4
counts.”
4. “The HIV won’t affect my baby, and I will have a low-risk pregnancy without additional
testing.”
Answer: 2
Rationale 1:
Most of the medications that control HIV progression are safe to take during pregnancy.
Antiretroviral medications are recommended during pregnancy to prevent perinatal
transmission.
Rationale 2:
Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV
antibodies. These antibodies clear over time, and an accurate test can be obtained by 15
months of age.
Rationale 3:
There is no evidence to indicate that pregnancy increases the progression of HIV/AIDS.
Rationale 4:
Pregnancy affected by HIV/AIDS is considered complicated, and the fetus is monitored
closely. Fetal assessments include weekly nonstress tests beginning at 32 weeks.
13) During her first antepartal visit, a patient who is at 10 weeks' gestation reports that she is
HIV-positive. Which statement made by the patient indicates an understanding of the plan of
care both during the pregnancy and postpartally?
1. "I'm supposed to take highly active antiretroviral therapy (HAART), but only during the
first trimester."
2. "I should not breastfeed my baby."
3. "If I have a cesarean section, there's an increased risk that my HIV will be passed to my
baby."
4. "When my baby is 2 months old, he or she will be tested for HIV."
Answer: 2
Rationale 1:
Longer duration therapy is preferable to shorter duration approaches, and it is best to start
prophylaxis after the first trimester and no later than 28 weeks’ gestation in women who do
not require immediate therapy for their own health.
Rationale 2:
HIV transmission can occur during pregnancy and through breast milk; however, it is
believed that the majority of all infections occur during labor and birth.
Rationale 3:
Cesarean section reduces the transmission of HIV from mother to infant.
Rationale 4:
Following birth, HIV infection in infants should be diagnosed using HIV virologic assays as
soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is
positive.
14) A woman is 32 weeks pregnant. She is HIV-positive, but asymptomatic. What would be
important in managing her pregnancy and delivery?
1. An amniocentesis at 30 and 36 weeks
2. Weekly nonstress testing beginning at 32 weeks’ gestation
3. Application of a fetal scalp electrode as soon as her membranes rupture in labor
4. Administration of intravenous antibiotics during labor and delivery
Answer: 2
Rationale 1:
All invasive procedures that would expose the uninfected infant to the HIV virus are avoided.
Rationale 2:
Patients who are HIV-positive are considered high-risk pregnancies. Therefore, beginning at
about 32 weeks, these patients have weekly nonstress tests to assess for placental function
and an ultrasound every 2–3 weeks to assess for intrauterine growth retardation (IUGR).
Rationale 3:
All invasive procedures that would expose the uninfected infant to the HIV virus are avoided.
Rationale 4:
Antibiotics would be ineffective for either the mother or the infant who was HIV-positive.
15) A pregnant woman is married to an intravenous drug user. She had a negative HIV
screening test just after missing her first menstrual period. What would indicate that the
patient needs to be retested for HIV?
1. Hemoglobin of 11 g/dL and a rapid weight gain
2. Elevated blood pressure and ankle edema
3. Shortness of breath and frequent urination
4. Unusual fatigue and recurring Candida vaginitis
Answer: 4
Rationale 1:
The patient would be anemic and anorexic.
Rationale 2:
The patient would have a decrease in blood pressure and no ankle edema.
Rationale 3:
Shortness of breath and frequent urination do not indicate a need to retest for HIV.
Rationale 4:
The patient who is HIV-positive would have a suppressed immune system and would
experience symptoms of fatigue and opportunistic infections such as Candida vaginitis.
16) The nurse is reviewing prenatal charts. A patient at 24 weeks has a history of class II
heart disease secondary to rheumatic fever. What would the nurse expect to see in the chart?
1. Dyspnea and chest pain with mild exertion
2. Elective cesarean birth scheduled for 37 weeks
3. Discussed need for labor epidural and vacuum extraction
4. Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally
Answer: 3
Rationale 1:
Dyspnea and angina with mild exertion are not expected with class II heart disease even
during pregnancy, but are symptoms seen in class IV heart disease.
Rationale 2:
Cesarean birth is only undertaken in cardiac patients for fetal or maternal intrapartal
indications, not for cardiac reasons alone.
Rationale 3:
Lumbar epidural analgesia decreases the stress response during labor, while vacuum
extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the
heart during birth.
Rationale 4:
3+ pre-tibial edema is never an expected finding during pregnancy. Pulse over 100 and
respiratory rate over 24 are indicators of cardiac decompensation.
17) The prenatal clinic nurse has received four phone calls. Which patient should be called
first?
1. Primip at 28 weeks with history of asthma reporting difficulty breathing and shortness of
breath
2. Multip at 6 weeks with a seizure disorder inquiring what foods are good folic acid sources
for her
3. Primip at 35 weeks with a positive HBsAG wondering what treatment her baby will
receive after birth
4. Multip at 11 weeks with untreated hyperthyroidism describing the onset of vaginal
bleeding
Answer: 1
Rationale 1:
Asthma exacerbations are most common between 24 and 36 weeks. Asthma attacks can lead
to maternal hypoxia, which can lead to fetal hypoxia. This patient is the top priority.
Rationale 2:
Women with seizure disorders should be started on folic acid supplements prior to pregnancy,
and should continue throughout pregnancy. This patient is not the highest priority.
Rationale 3:
A patient with a positive HBsAG is contagious for hepatitis B. The risk of transmission to the
fetus at birth is reduced by bathing the neonate as soon as possible after birth and giving the
infant immunoprophylaxis and the first HBsAG vaccine dose. The patient seeking
information about what will happen after delivery is a low priority when there are pregnant
patients currently experiencing physiologic problems.
Rationale 4:
Pregnant women with untreated hyperthyroidism have an increased risk of fetal loss. Vaginal
bleeding at 11 weeks could indicate that spontaneous abortion is taking place. But the
majority of spontaneous abortions prior to 12 weeks’ gestation are complete and without
complications. This patient is not experiencing a normal pregnancy, but the health of both
mother and fetus are not in immediate danger.
18) The patient was found to have hepatitis B surface antigen (HBsAG) early in her
pregnancy. The nurse is explaining to the patient what will happen during labor and birth
because the patient is contagious for hepatitis B. Which statement by the patient indicates that
additional teaching is needed?
1. “An internal fetal monitor will be applied as soon as possible during labor.”
2. “My baby will get a bath as soon as its temperature is stable.”
3. “Two shots will be given to my baby to prevent transmission of hepatitis B.”
4. “Breastfeeding is a good feeding method for my baby.”
Answer: 1
Rationale 1:
An internal fetal monitor will be avoided.
Rationale 2:
The presence of hepatitis B surface antigen (HBsAG) indicates that the patient is contagious
for and capable of transmitting hepatitis B. Perinatal transmission is most likely to occur at
the time of birth; thus, measures are taken to prevent exposing the fetus to the mother’s blood
and body fluids and to clean the baby’s skin thoroughly of fluids as soon as possible after
birth.
Rationale 3:
A newborn of a mother with HBsAG will receive an injection of hepatitis B immune globulin
and a hepatitis B vaccine injection.
Rationale 4:
Breastfeeding is not contraindicated in a patient with HBsAG.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
