Preview Extract
Chapter 21
1) The nurse is caring for a patient at 30 weeks’ gestation who is experiencing preterm
premature rupture of membranes (PPROM). Which statement indicates that the patient needs
additional teaching? “If I:
1. “Were having a singleton pregnancy instead of twins, my membranes would probably not
have ruptured.”
2. “Develop a urinary tract infection in my next pregnancy, I might rupture membranes early
again.”
3. “Want to become pregnant again, I will have to plan on being on bed rest for the whole
pregnancy.”
4. “Have bleeding in the third trimester of my next pregnancy, I might rupture membranes
again.”
Answer: 3
Rationale 1:
Multifetal gestation increases the risk for PPROM.
Rationale 2:
A UTI increases the risk for PPROM.
Rationale 3:
There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for
PPROM.
Rationale 4:
Second- and third-trimester bleeding increases the risk for PPROM.
2) A clinical nurse coordinator is teaching a class of nursing students about surgical and
postoperative care of the woman who undergoes cerclage. Which nursing student’s statement
indicates the need for further clarification of the teaching?
1. “Sometimes cerclage can be performed on an outpatient basis.”
2. “If cerclage is performed emergently, the woman will usually be hospitalized for at least
five days.”
3. “If the woman’s amniotic sac is bulging, the cerclage is contraindicated and the procedure
cannot be performed.”
4. “After 37 weeks’ gestation, the woman’s cerclage may be cut in order to allow for vaginal
delivery.”
Answer: 3
Rationale 1:
An uncomplicated elective cerclage may be done on an outpatient basis or the woman may be
hospitalized and discharged after 24 to 48 hours. An emergency cerclage, however, requires
hospitalization for 5 to 7 days or longer.
Rationale 2:
An uncomplicated elective cerclage may be done on an outpatient basis or the woman may be
hospitalized and discharged after 24 to 48 hours. An emergency cerclage, however, requires
hospitalization for 5 to 7 days or longer.
Rationale 3:
Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the
amniotic sac must be decompressed immediately before the procedure.
Rationale 4:
After 37 completed weeks’ gestation, the suture may be cut and vaginal birth permitted, or
the suture may be left in place and a cesarean birth performed.
3) A 26-year-old woman who is pregnant with her first child is admitted to the obstetrics unit
with a diagnosis of cervical insufficiency. Based upon the patient’s diagnosis, how is she
most likely to describe her symptoms?
1. “I’ve been having contractions every four hours.”
2. “My cervical pain has gotten much worse over the past two days.”
3. “I’m not having any pain, but my contractions are getting stronger.”
4. “I’m not having any pain and I don’t feel any contractions.”
Answer: 4
Rationale 1:
Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix
without contractions due to a structural or functional defect of the cervix.
Rationale 2:
Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix
without contractions due to a structural or functional defect of the cervix.
Rationale 3:
Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix
without contractions due to a structural or functional defect of the cervix.
Rationale 4:
Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix
without contractions due to a structural or functional defect of the cervix.
4) The nurse has received an end of shift report in the high-risk maternity unit. Which patient
should the nurse see first?
1. 26 weeks’ gestation with placenta previa experiencing blood on toilet tissue after a bowel
movement
2. 30 weeks’ gestation with placenta previa whose fetal monitor strip shows late decelerations
3. 35 weeks’ gestation with grade I abruptio placentae in labor who has a strong urge to push
4. 37 weeks’ gestation with pregnancy-induced hypertension whose membranes ruptured
spontaneously
Answer: 1
Rationale 1:
Bleeding with a placenta previa is a complication that can be life-threatening to both the
mother and baby. This patient is the highest priority.
Rationale 2:
Late decelerations are an abnormal finding, but put only the fetus at risk. This patient is not
the highest priority.
Rationale 3:
Grade I abruptio placentae creates slight vaginal bleeding. The urge to push indicates that
delivery is near. This patient is not the highest priority.
Rationale 4:
Although pregnancy-induced hypertension puts a woman at risk for developing abruptio
placentae, there is no indication that this patient is experiencing this complication. This
patient is not the highest priority.
5) The nurse is planning an in-service educational program to talk about disseminating
intravascular coagulation (DIC). The nurse should identify which of the following as risk
factors for developing DIC?
1. Diabetes mellitus
2. Abruptio placentae
3. Prolonged retention of a fetus after demise
4. Multiparity
5. Preterm labor
Answer: 2,3
Rationale 1:
Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that
triggers DIC.
Rationale 2:
Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the
degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting
system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and
factors V and VII, and result in DIC.
Rationale 3:
Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the
degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting
system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and
factors V and VII, and result in DIC.
Rationale 4:
Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that
triggers DIC.
Rationale 5:
Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that
triggers DIC.
6) The patient at 30 weeks’ gestation is admitted with painless late vaginal bleeding. The
nurse understands that expectant management includes:
1. Limiting vaginal exams to only one per 24-hour period.
2. Evaluating the fetal heart rate with an internal monitor.
3. Monitoring for blood loss, pain, and uterine contractibility.
4. Assessing blood pressure every 2 hours.
Answer: 3
Rationale 1:
Vaginal exams are contraindicated because the exam can stimulate bleeding.
Rationale 2:
Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is
covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal
monitor.
Rationale 3:
Blood loss, pain, and uterine contractibility need to be assessed for patient comfort and
safety.
Rationale 4:
Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine
basis or p.r.n.
7) A multigravida patient is admitted to labor and delivery in active labor. Nursing diagnoses
that might apply to the patient with suspected abruptio placentae include:
1. Fluid volume, risk for deficit related to hypovolemia.
2. Tissue perfusion, risk for altered related to blood loss.
3. Anxiety related to concern for own safety.
4. Knowledge deficit related to lack of information about inherited genetic defects.
Answer: 1,2,3
Rationale 1:
Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.
Rationale 2:
Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.
Rationale 3:
Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.
Rationale 4:
Abruptio placentae is a premature separation of the placenta, not a genetic abnormality.
8) The charge nurse is reviewing the physician’s notes describing the diagnosis of abruptio
placentae in a patient who is currently admitted. The physician describes the woman’s
placental separation as being “central.” Based upon this description, what can the nurse infer
about the woman’s condition?
1. Blood is trapped between the woman’s placenta and the uterine wall, and she may have
concealed bleeding.
2. The total separation of the woman’s placenta from the uterine wall will lead to massive
hemorrhage.
3. Blood is passing between the fetal membranes and the woman’s uterine wall, which will
lead to some vaginal bleeding.
4. The slight separation of the woman’s placenta from the uterine wall will not produce any
bleeding.
Answer: 1
Rationale 1:
With the central type of placental separation, blood is trapped between the placenta and
uterine wall with concealed bleeding.
Rationale 2:
With marginal placental separation, blood passes between the fetal membranes and the
uterine wall and escapes vaginally. With central placental separation, blood is trapped
between the placenta and uterine wall, and bleeding is concealed. With complete separation,
there is total separation of the placenta from the uterine wall, and massive bleeding ensues.
Rationale 3:
With marginal placental separation, blood passes between the fetal membranes and the
uterine wall and escapes vaginally. With central placental separation, blood is trapped
between the placenta and uterine wall, and bleeding is concealed. With complete separation,
there is total separation of the placenta from the uterine wall, and massive bleeding ensues.
Rationale 4:
With marginal placental separation, blood passes between the fetal membranes and the
uterine wall and escapes vaginally. With central placental separation, blood is trapped
between the placenta and uterine wall, and bleeding is concealed. With complete separation,
there is total separation of the placenta from the uterine wall, and massive bleeding ensues.
9) The home health nurse is admitting a patient at 18 weeks who is pregnant with twins.
Which nursing action is most important?
1. Teach the patient about foods that are good sources of protein.
2. Assess the patient’s blood pressure in her upper right arm.
3. Determine whether the pregnancy is a result of infertility treatment.
4. Collect a cervicovaginal fetal fibronectin (fFN) specimen.
Answer: 1
Rationale 1:
A diet containing 3,500 kcal (minimum) and 175 g protein is recommended for a woman with
normal-weight twins. Teaching about protein sources facilitates adequate fetal growth.
Rationale 2:
Pre-eclampsia is not diagnosed until the 20th week of gestation. This patient is only at 18
weeks. Further, blood pressure can be assessed in either arm when the patient is in a sitting
position; in a side-lying position, the blood pressure should be assessed in the upper arm.
Rationale 3:
Although the incidence of multifetal pregnancy is higher in pregnancies resulting from
infertility treatment than in those resulting from spontaneous pregnancies, the cause of the
multifetal pregnancy does not impact nursing care.
Rationale 4:
Preterm labor is not diagnosed until 20 weeks. This patient is only at 18 weeks. Fetal
fibronectin (fFN) testing is not indicated at this time.
10) In counseling a newly pregnant gravida 1 at 8 weeks’ twin gestation, the nurse teaches
the woman about the need for increased caloric intake. The nurse would tell the woman that
the minimum recommended intake should be:
1. 2,500 kcal and 120 grams protein.
2. 3,000 kcal and 150 grams protein.
3. 3,500 kcal and 175 grams protein.
4. 4,000 kcal and 190 grams protein.
Answer: 3
Rationale 1:
This is less than recommended for a twin-gestation pregnancy.
Rationale 2:
This is less than recommended for a twin-gestation pregnancy.
Rationale 3:
This is the recommended caloric and protein intake in a twin-gestation pregnancy.
Rationale 4:
This is more than recommended for a twin-gestation pregnancy.
11) When a woman who is experiencing a multiple fetal pregnancy asks, “What are the
chances of having an uncomplicated pregnancy?” the nurse answers with which statement?
1. The perinatal mortality rate for monoamniotic siblings is 50%.
2. Twins are less likely to have complications than are singleton births.
3. Primiparous women pregnant with twins are less likely to develop complications.
4. Spontaneously conceived twins are less likely to develop complications.
Answer: 4
Rationale 1:
The perinatal mortality rate for monoamniotic siblings is 10–32%.
Rationale 2:
Twins are more likely to have complications than are singleton births.
Rationale 3:
Primiparous women with twin pregnancies are more likely to develop complications.
Rationale 4:
This is true. Spontaneously conceived twins are less likely to develop complications.
12) The patient at 38 weeks’ gestation has been diagnosed with oligohydramnios. Which
statement indicates that teaching has been effective?
1. “My gestational diabetes may have caused this problem to develop.”
2. “When I go into labor, I should come to the hospital right away.”
3. “This problem is common and will likely occur with my next pregnancy.”
4. “Women with this condition usually go into labor after their due date.”
Answer: 2
Rationale 1:
Gestational diabetes can lead to polyhydramnios but does not cause oligohydramnios.
Rationale 2:
The incidence of cord compression and resulting fetal distress is high when there is an
inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the patient with
oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of
labor that might develop.
Rationale 3:
Oligohydramnios occurs in 1–3% of pregnancies. It rarely recurs in subsequent pregnancies.
Rationale 4:
The risk of fetal demise is increased with oligohydramnios. Labor is usually induced when
the patient reaches term pregnancy to prevent fetal demise.
13) The nurse is admitting a patient who was diagnosed with hydramnios. The patient asks
why she has developed this condition. The nurse should explain that hydramnios is
sometimes associated with:
1. Chest pain, dyspnea, tachycardia, and hypotension.
2. Postmaturity syndrome.
3. Renal malformation or dysfunction.
4. Maternal diabetes.
5. Large-for-gestational-age infants.
Answer: 1,2,4
Rationale 1:
Chest pain, dyspnea, tachycardia, and hypotension are symptoms of amniotic embolism,
which occurs more commonly with hydramnios. Hydramnios occurs in 10–20% of pregnant
diabetics.
Rationale 2:
Renal malformation or dysfunction and postmaturity can cause oligohydramnios.
Rationale 3:
Renal malformation or dysfunction and postmaturity can cause oligohydramnios.
Rationale 4:
Hydramnios is not associated with maternal diabetes.
Rationale 5:
Large-for-gestational-age infants and placenta previa are not associated with hydramnios.
14) When caring for a laboring patient with oligohydramnios, the nurse should be aware that:
1. There is an increased risk of cord compression.
2. There is less fluid available for the fetus to use during fetal breathing movements;
therefore, pulmonary hypoplasia can develop, which could cause respiratory difficulties at
birth.
3. Labor progress is often more rapid than average.
4. Early decelerations are more likely.
Answer: 1,2,4
Rationale 1:
Less amniotic fluid lessens the cushioning effect, and cord compression is more likely.
Rationale 2:
Rationale 3:
Labor progress is slower than average due to the decreased fluid volume.
Rationale 4:
Decreased amniotic fluid can contribute to fetal head compression, which manifests itself in
early decelerations.
15) Hydramnios most likely would be suspected when:
1. There is less amniotic fluid than normal for gestation.
2. The fundal height increases disproportionately to the gestation.
3. The woman has a twin gestation.
4. The quadruple screen comes back positive.
Answer: 2
Rationale 1:
Hydramnios occurs when there is more amniotic fluid than normal for gestation.
Rationale 2:
The increased amount of amniotic fluid will increase the fundal height disproportionately to
the gestation.
Rationale 3:
Hydramnios is not suspected simply by virtue of a twin gestation.
Rationale 4:
A positive quadruple screen is not indicative of hydramnios.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
