Chapter 16
1) The nurse is supervising care in the emergency department. Which situation most requires
an intervention?
1. Moderate vaginal bleeding at 36 weeks’ gestation; patient has an IV of lactated Ringer’s
solution running at 125 mL/hour
2. Spotting of pinkish-brown discharge at 6 weeks’ gestation and abdominal cramping;
ultrasound scheduled in one hour
3. Bright red bleeding with clots at 32 weeks’ gestation; pulse = 110, blood pressure 90/50,
respirations = 20
4. Dark red bleeding at 30 weeks’ gestation with normal vital signs; patient reports an
absence of fetal movement
Answer: 3
Rationale 1:
Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss
can be heavy and rapid, so having an IV stabilizes the patient’s vascular volume.
Rationale 2:
Bleeding in the first trimester can be indicative of spontaneous abortion beginning or of an
ectopic pregnancy. An ultrasound will diagnose which situation is occurring and will
determine care. Because this patient is very early in the pregnancy and only experiencing
spotting, it is not appropriate to have an IV at this time.
Rationale 3:
Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss
can be heavy and rapid. This patient has a low blood pressure with an increased pulse rate,
which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby.
Both lives are at risk in this situation. Since there is no information given that the patient has
an IV started, this patient is the least stable, and therefore the highest priority.
Rationale 4:
Watery, dark red bleeding in the third trimester can indicate placental abruption with ruptured
membranes. Normal vital signs indicate a normal vascular volume. A lack of fetal movement
could indicate fetal hypoxia or fetal demise. The fetus is at greatest risk in this situation; the
mother is stable.
2) The prenatal clinic nurse is caring for a patient with hyperemesis gravidarum at 14 weeks’
gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order
should the nurse implement first?
1. Weigh the patient.
2. Give 1 liter of lactated Ringer’s solution IV.
3. Administer 30 ml Maalox (magnesium hydroxide) orally.
4. Encourage clear liquids orally.
Answer: 2
Rationale 1:
Weighing the patient provides information on weight gain or loss, but it is not the top priority
in a patient with excessive vomiting during pregnancy. The vital signs indicate hypovolemia.
The patient needs IV fluids.
Rationale 2:
The vital signs indicate hypovolemia. Giving this patient a liter of lactated Ringer’s solution
intravenously will re-establish vascular volume and bring the blood pressure up, and the pulse
and respiratory rate down.
Rationale 3:
The vital signs indicate hypovolemia. There is no indication that the patient has dyspepsia.
The patient needs IV fluids.
Rationale 4:
The patient needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are
not likely to be tolerated well by a patient with hyperemesis. Lack of tolerance of oral fluids
through excessive vomiting is what has led to the hypovolemia.
3) A 28-year-old woman who is at 16 weeks’ gestation has just undergone screening for ABO
incompatibility. She asks the nurse why her blood contains anti-A antibodies. What is the
nurse’s best response?
1. “Anti-A antibodies occur naturally, as a result of exposure to foods and different
infections.”
2. “It’s most likely that you contracted anti-A antibodies through sexual activity.”
3. “Anti-A antibodies are inherited; usually, they are genetically passed down from father to
daughter.”
4. “You may have contracted anti-A antibodies as a result of a viral infection.”
Answer: 1
Rationale 1:
Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to
the A and B antigens through the foods they eat and through exposure to infection by gram
negative bacteria.
Rationale 2:
Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to
the A and B antigens through the foods they eat and through exposure to infection by gram
negative bacteria.
Rationale 3:
Women develop anti-A and anti-B antibodies naturally as a result of exposure to the A and B
antigens through the foods they eat and through exposure to infection by gram negative
bacteria.
Rationale 4:
Women develop anti-A and anti-B antibodies as a result of exposure to the A and B antigens
through infection by gram negative bacteria, as well as through exposure to the foods they
eat.
4) While preparing a class on maternal-fetal ABO incompatibility for antepartum patients, the
nurse is creating a brochure. Which statement should be included in the brochure
information?
1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus.
2. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are
never affected regardless of the mother’s blood type.
3. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus.
4. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction
between the antigen sites on the maternal RBCs.
Answer: 3
Rationale 1:
In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus.
The group B fetus of a group A mother and the group A fetus of a group B mother are only
occasionally affected.
Rationale 2:
Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are
never affected regardless of the mother’s blood type.
Rationale 3:
In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus.
The group B fetus of a group A mother and the group A fetus of a group B mother are only
occasionally affected.
Rationale 4:
The incompatibility occurs as a result of the maternal antibodies present in her serum and
interaction between the antigen sites on the fetal RBCs.
5) A patient who is at 32 weeks’ gestation is determined to be at high risk for ABO
incompatibility. Which intervention should the nurse anticipate implementing?
1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM) to the patient
2. Notify the patient’s primary care provider and document the potential need for treatment of
fetal hemolytic anemia in the patient’s baby after delivery.
3. Obtain an antibody screen (indirect Coombs’ test) to determine whether the patient has
developed isoimmunity.
4. Note the potential for ABO incompatibility and plan to carefully assess the patient’s
neonate for the development of hyperbilirubinemia.
Answer: 4
Rationale 1:
RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood.
Rationale 2:
Unlike Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted
because it does not cause severe anemia.
Rationale 3:
An antibody screen (indirect Coombs’ test) is done to determine whether an Rh-negative
woman is sensitized (has developed isoimmunity) to the Rh antigen.
Rationale 4:
Unlike Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted
because it does not cause severe anemia. As part of the initial assessment, however, the nurse
should note whether the potential for an ABO incompatibility exists in order to alert
caregivers to the need for carefully assessing the newborn for the development of
hyperbilirubinemia.
6) The nurse identifies the following assessment findings on a patient with pre-eclampsia:
blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein
11 on dipstick; and edema of the hands, ankles, and feet. On the next hourly assessment,
which of the following new assessment findings would be an indication of worsening of the
pre-eclampsia?
1. Blood pressure 158/104
2. Urinary output 20 mL/hour
3. Reflexes 21
4. Platelet count 150,000
Answer: 2
Rationale 1:
The blood pressure has not had a significant rise.
Rationale 2:
The decrease in urine output is an indication of decrease in GFR, which indicates a loss of
renal perfusion. The assessment finding most abnormal and life-threatening is the urine
output change.
Rationale 3:
The reflexes are normal at 21.
Rationale 4:
The platelet count is normal, though it is at the lower end.
7) The community nurse is working with a patient at 32 weeks’ gestation who has been
diagnosed with pre-eclampsia. Which statement indicates that additional information is
needed?
1. “I should call the doctor if I develop a headache or blurred vision.”
2. “Lying on my left side as much as possible is good for the baby.”
3. “My urine may become darker and smaller in amount each day.”
4. “Pain in the top of my abdomen is a sign my condition is worsening.”
Answer: 3
Rationale 1:
Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the physician.
Rationale 2:
Left lateral position maximizes uterine and renal blood flow and therefore is the optimal
position for a patient with pre-eclampsia.
Rationale 3:
Oliguria is a complication of pre-eclampsia caused by renal involvement and is a sign that the
condition is worsening. Oliguria should be reported to the physician.
Rationale 4:
Epigastric pain is an indication of liver enlargement, a symptom of worsening pre-eclampsia,
and should be reported to the physician.
8) The nurse is assessing a newly admitted patient who is 32 weeks’ gestation. The patient’s
chief complaints are sudden onset of intense nausea and a frontal headache for the past two
days. The patient’s initial blood pressure is 158/98 and she reports scant urination over the
past 24 hours. Which intervention should the nurse anticipate implementing?
1. Placing a wedge under the patient’s left hip so that she is in a right lateral tilt position
2. Administration of diuretics and facilitating a dietary regimen of strict sodium restriction
3. Conducting a urine dipstick test to assess for proteinuria
4. Ordering a low-protein diet plan for the patient
Answer: 3
Rationale 1:
This patient’s signs and symptoms are consistent with pre-eclampsia. Appropriate
interventions include instituting bed rest with the patient positioned primarily on her left side,
to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume,
and placental and renal perfusion.
Rationale 2:
This patient’s signs and symptoms are consistent with pre-eclampsia. Treatment includes
avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used
in treating pre-eclampsia.
Rationale 3:
This patient’s signs and symptoms are consistent with pre-eclampsia. Treatment includes
daily urine dipstick testing to assess for proteinuria.
Rationale 4:
This patient’s signs and symptoms are consistent with pre-eclampsia. Dietary interventions
include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/ day) to replace protein
lost in the urine.
9) The nurse receives the following report on a patient who delivered 36 hours ago: para 1,
rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs’
negative, discharge orders are written for both mother and newborn. What should be the
priority action by the nurse?
1. Ask if she is breast- or bottle-feeding.
2. Administer rubella vaccine.
3. Determine if RhoGAM has been given.
4. Discuss the discharge education with the patient.
Answer: 3
Rationale 1:
This is important but is not the top priority.
Rationale 2:
The patient is rubella-immune and does not need the rubella vaccine.
Rationale 3:
The patient is A-negative and the newborn B-positive. The patient needs RhoGAM prior to
discharge. Without RhoGAM, the patient will make antibodies against Rh-positive blood, and
future pregnancies would be in jeopardy.
Rationale 4:
Discharge education is always important, but in this case it is not the most important action.
10) The patient with blood type A, Rh-negative delivered yesterday. Her infant is blood type
AB, Rh-positive. Which statement indicates that teaching has been effective?
1. “I need to get RhoGAM so I don’t have problems with my next pregnancy.”
2. “Because my baby is Rh-positive, I don’t need RhoGAM.”
3. “If my baby had the same blood type I do, it might cause complications.”
4. “Before my next pregnancy, I will need to have a RhoGAM shot.”
Answer: 1
Rationale 1:
Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune
globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other
complications during the next pregnancy.
Rationale 2:
Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune
globulin (RhoGAM) to prevent alloimmunization.
Rationale 3:
It is specifically the Rh factor that causes complications; ABO grouping does not cause
alloimmunization.
Rationale 4:
Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune
globulin (RhoGAM). The injection must be given with 72 hours after delivery to prevent
alloimmunization.
11) Which maternal–child patient should the nurse see first?
1. Blood type O, Rh-negative
2. Indirect Coombs’ test negative
3. Direct Coombs’ test positive
4. Blood type B, Rh-positive
Answer: 3
Rationale 1:
This patient is Rh-negative, but there is no indication that the alloimmunization has occurred.
Rationale 2:
An indirect Coombs’ test looks for Rh antibodies in the maternal serum; a negative result
indicates the patient has not been alloimmunized.
Rationale 3:
A direct Coombs’ test looks for Rh antibodies in the fetal blood circulation. A positive result
indicates that that there is an Rh incompatibility between mother and infant, and the baby is
making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia
and hyperbilirubinemia.
Rationale 4:
This patient’s blood type creates no problems.
12) Which situation in the high-risk antepartal unit requires immediate intervention?
1. A third-trimester patient pregnant with twins who required an appendectomy yesterday is
positioned in a supine position.
2. Oxygen is being administered at 2 L via nasal cannula to a patient in her third trimester
who underwent an urolithotomy today.
3. Fetal monitoring is being performed on a patient in her third trimester who is scheduled for
a cholecystectomy tomorrow.
4. The patient in her third trimester who returned from bowel resection surgery has a
nasogastric tube attached to intermittent suction.
Answer: 1
Rationale 1:
A patient undergoing surgery in the third trimester should be positioned in a left lateral
position or with a hip wedge placed. Being supine will cause vena cava syndrome and
hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger
uterus and heavier uterine contents, makes vena cava syndrome more problematic.
Rationale 2:
Oxygen is required during and after surgery during pregnancy to maintain adequate fetal
oxygenation.
Rationale 3:
Fetal monitoring prior to, during, and after surgery on pregnant patients is important to assess
the fetal condition.
Rationale 4:
Due to the decreased peristalsis of pregnancy, pregnant patients who undergo abdominal
surgery are at risk for vomiting. An NG tube is placed to prevent vomiting.
13) The nurse is caring for a patient at 35 weeks’ gestation who has been critically injured in
a shooting. Which statement by the paramedics bringing the woman to the hospital would
cause the greatest concern?
1. “Blood pressure 110/68, pulse 90.”
2. "Entrance wound present below the umbilicus.”
3. “Patient is positioned in a left lateral tilt.”
4. “Clear fluid is leaking from the vagina.”
Answer: 2
Rationale 1:
These are normal vital signs, indicating a hemodynamically stable patient.
Rationale 2:
Penetrating abdominal trauma has a 59–80% fetal injury rate. This fetus is at great risk for
injury.
Rationale 3:
Positioning the patient in a lateral tilt position prevents vena cava syndrome.
Rationale 4:
Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the
membranes. Although this is not a normal finding at 35 weeks, this fetus is near term and
would likely survive birth at this time.
14) The nurse is admitting a patient at 28 weeks’ gestation to the emergency department
following an episode of domestic abuse resulting in ecchymosis and lacerations. Which
question is most critical to ask?
1. “What did you do to make your spouse so angry?”
2. “How many times has this happened in the past?”
3. “Do you have a safe place that you can go?”
4. “Will you be pressing charges against your spouse?”
Answer: 3
Rationale 1:
This statement is blaming and must be avoided to establish a trusting, therapeutic relationship
with an abused patient.
Rationale 2:
Although domestic abuse tends to increase in frequency and violence during pregnancy, this
is not the highest priority.
Rationale 3:
This question is the highest priority because having a safe place to go after leaving the
hospital reduces the risk of a repeated attack and further injury to both mother and fetus.
Rationale 4:
Legal issues are a low priority at this time. Physiologic issues such as safety in the future
have more importance.
15) Which statement indicates that teaching has been effective?
1. “Because I have toxoplasmosis, my baby might be born with an abnormally long body.”
2. “The rubella infection I experienced in my second trimester may lead me to become deaf.”
3. “My baby may develop a serious blood infection because I have group B strep in my
vagina.”
4. “My 8-year-old’s parvovirus infection won’t affect my baby because I am four months
along.”
Answer: 3
Rationale 1:
Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma,
convulsions, or retinochoroiditis.
Rationale 2:
Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and
developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella.
Rationale 3:
Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are
given during labor.
Rationale 4:
Parvovirus effects on the fetus are most severe when the maternal infection occurs prior to
the 20th week.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
