Preview Extract
Chapter 32
1) The nurse is preparing a community education class on healthy pregnancy. Which
statements should be included?
1. Eating a well-balanced diet helps prevent pregnancy complications.
2. Stress management and support systems are important in pregnancy.
3. Prenatal care can be obtained at any point in the pregnancy.
4. Complications during a prior pregnancy do not recur.
5. Exercising regularly facilitates feeling better in pregnancy.
Answer: 1,2,5
Rationale 1:
Good overall nutrition helps reduce the incidence of many pregnancy complications,
including anemia, preterm labor, and delivery complications such as shoulder dystocia.
Rationale 2:
Patients with high stress levels and poor support systems are more likely to develop
postpartum depression and have problems parenting.
Rationale 3:
Early and regular prenatal care is important to provide education that can help prevent
complications, and to detect complications as they develop.
Rationale 4:
Many complications of pregnancy have a tendency to recur, including postpartum
hemorrhage, postpartum depression, preterm labor, and premature rupture of membranes.
Rationale 5: Regular exercise during pregnancy helps prevent hypertension and gestational
diabetes, helps reduce length of labor, and helps patients feel good.
2) A patient is 3 days postop from a cesarean birth. She has tenderness, localized heat, and
redness of the left leg. She is afebrile. As a result of these symptoms, she most likely will be:
1. Encouraged to ambulate freely.
2. Given aspirin 650 mg by mouth.
3. Given Methergine IM.
4. Placed on bed rest.
Answer: 4
Rationale 1:
That would increase the inflammation.
Rationale 2:
Aspirin 650 mg by mouth has anticoagulant properties, but usually is not necessary unless
complications occur.
Rationale 3:
Methergine is given only for postpartum hemorrhage, and would only cause vasoconstriction
of an already inflamed vessel.
Rationale 4:
These symptoms indicate the presence of superficial thrombophlebitis. The treatment
involves bed rest and elevation of the affected limb, analgesics, and use of elastic support
hose.
3) The nurse is assisting a multiparous woman to the bathroom for the first time since her
delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the
floor. The patient turns pale and feels weak. The first action of the nurse is to:
1. Assist the patient to empty her bladder.
2. Help the patient back to bed to check her fundus.
3. Assess her blood pressure and pulse.
4. Begin an IV of Lactated Ringer’s infusion.
Answer: 2
Rationale 1:
The patient might be experiencing a postpartum hemorrhage. Her fundus is not contracting
well. Although this might be due to a full bladder, the best first step is to massage the fundus.
Rationale 2:
Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is
boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss.
Rationale 3:
Massaging the fundus is the top priority because of the excessive blood loss. Blood pressure
and pulse do not change until 1000–2000 ml of blood has been lost. Massaging the fundus
will prevent further blood loss.
Rationale 4:
Massaging the fundus is the top priority because of the excessive blood loss. An IV might
need to be started if the patient becomes symptomatic.
4) A patient is experiencing excessive bleeding immediately after the birth of her newborn.
After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the
bleeding, the nurse should anticipate the physician requesting which medications?
1. Methergine
2. Stadol
3. Misoprostol
4. Betamethasone
Answer: 1,3
Rationale 1:
Methergine is a drug of choice for postpartum hemorrhage.
Rationale 2:
Stadol is an analgesic, and is not used for postpartum hemorrhage.
Rationale 3:
Misoprostol is commonly administered rectally for postpartum hemorrhage.
Rationale 4:
Betamethasone is a glucocorticoid used for preterm labor in an attempt to decrease
respiratory distress in the preterm infant.
5) The postpartum patient who delivered 2 days ago has developed endometritis. Which
charting entry would the nurse expect to find in this patient’s chart?
1. “Cesarean birth performed secondary to arrest of dilation.”
2. “Rupture of membranes occurred 2 hours prior to delivery.”
3. “External fetal monitoring used throughout labor.”
4. “Patient has history of pregnancy-induced hypertension.”
Answer: 1
Rationale 1:
Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical
exams necessary to assess for arrest of dilation are another risk factor for postpartum
infection.
Rationale 2:
Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum
endometritis.
Rationale 3:
Internal fetal monitoring (both internal fetal scalp electrode and intrauterine pressure
catheter) are risk factors for postpartum endometritis.
Rationale 4:
Pregnancy-induced hypertension is not a risk factor for development of postpartum
endometritis.
6) The patient at 3 days postpartum has come to the maternity clinic with complaints of
urinary urgency and dysuria. Which statement is most important for the nurse to make?
1. “Void into this sterile cup without touching the inside of the cup.”
2. “Be sure to wipe from back to front after you have a bowel movement.”
3. “Call the clinic if you develop nausea and vomiting or constipation.”
4. “Decrease your fluid intake for a few days, but eat a lot of vegetables.”
Answer: 1
Rationale 1:
A clean-catch urine sample will need to be obtained for urinalysis to determine if the patient
has developed a urinary tract infection.
Rationale 2:
Patients should be taught to wipe from front to back after bowel movements in order to
prevent contamination of the urethra and bladder with normal bowel flora.
Rationale 3:
A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever
and flank pain. Constipation is not associated with urinary tract infections.
Rationale 4:
Patients should increase their fluid intake but decrease their consumption of carbonated
beverages. Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables
do not help clear or prevent urinary tract infections.
7) Which method of initial assessment would best indicate whether a patient has a urinary
complication?
1. Urine pH
2. Calculation of urine output
3. Urine-specific gravity
4. Calculation of intake
Answer: 2
Rationale 1:
Urine pH and urine-specific gravity can be used to identify certain conditions, but would not
be part of the initial assessment.
Rationale 2:
Calculation of output would provide a better assessment of complete emptying of the bladder,
because overdistention can cause trauma to the bladder, displace the uterus, and cause
infection.
Rationale 3:
Urine pH and urine-specific gravity can be used to identify certain conditions, but would not
be part of the initial assessment.
Rationale 4:
Monitoring intake is an intervention that may help prevent urinary complications but
calculating the intake itself would not indicate a complication.
8) The postpartum multipara is breastfeeding her new baby. The patient states that she
developed mastitis with her first child, and asks if there is something she can do to prevent
mastitis this time. The best response of the nurse is:
1. “Massage your breasts on a daily basis, and if you find a hardened area, massage it towards
the nipple to unblock that duct.”
2. “Most first-time moms experience mastitis. It is really quite unusual for a woman having
her second baby to get it again.”
3. “Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling
and stasis of the milk in that area.”
4. “Take your temperature once a day. This will help you to pick up the infection early,
before it becomes severe.”
Answer: 1
Rationale 1:
A hardened area could indicate a blocked duct. Massage of the blocked duct toward the
nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis.
Rationale 2:
It is not unusual for mothers to develop complications similar to those experienced in prior
pregnancies.
Rationale 3:
Warm packs, not cold packs, should be applied to areas that are warm, red, or hardened.
Rationale 4:
The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful
for catching early onset of the infection. Massaging the area to unplug the duct and relieve
milk stasis is much more effective.
9) A nurse suspects that a postpartum patient has mastitis. The following assessment provides
what data to support this assessment?
1. Shooting pain in her nipple during breastfeeding.
2. Late onset of nipple pain
3. Pink, flaking, pruritic skin of the affected nipple.
4. Nipple soreness when the infant latches on.
Answer: 1,2,3
Rationale 1:
Mastitis is characterized by late-onset nipple pain, followed by shooting pain during and
between feedings.
Rationale 2:
Mastitis is characterized by late-onset nipple pain, followed by shooting pain during and
between feedings.
Rationale 3:
The skin of the affected breast becomes pink, flaking, and pruritic.
Rationale 4:
Nipple soreness, engorgement, and the letdown reflex do not share these symptoms.
10) The postpartum patient has developed thrombophlebitis in her right leg. Which finding
requires immediate intervention? The patient:
1. The postpartum patient has developed thrombophlebitis in her right leg. Which finding
requires immediate intervention? The patient:
2. Develops pain and swelling in her left lower leg.
3. Appears anxious, and describes pressure in her chest.
4. Becomes upset that she can’t go home yet.
Answer: 3
Rationale 1:
This is a risk factor for the development of thrombophlebitis, but neither a predictor nor an
indication of complications.
Rationale 2:
Development of bilateral thrombophlebitis is a complication, but not the top priority.
Rationale 3:
Anxiety and sudden onset of chest pain or pressure might indicate pulmonary embolus, which
is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and
requires immediate intervention.
Rationale 4:
Although the nurse provides patient care with the aim of keeping patients satisfied and
comfortable, becoming upset is a psychosocial issue, and far less important than development
of a pulmonary embolus.
11) The nurse is revising the care plan of a 26-year-old woman who has developed mastitis.
Which nursing diagnosis is most appropriate for inclusion in this patient’s updated plan of
care?
1. Ineffective Peripheral Tissue Perfusion related to obstructed venous return
2. Risk for Trauma related to lack of information about appropriate breastfeeding practices.
3. Deficient Knowledge related to self-care after discharge on anticoagulant therapy
4. Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction
Answer: 2
Rationale 1:
In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma
related to lack of information about appropriate breastfeeding practices.
Rationale 2:
In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma
related to lack of information about appropriate breastfeeding practices.
Rationale 3:
In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma
related to lack of information about appropriate breastfeeding practices.
Rationale 4:
In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma
related to lack of information about appropriate breastfeeding practices.
12) The nurse is calling postpartum patients. Which patient should be seen immediately? The
patient at 4 weeks postpartum who:
1. Describes feeling sad all the time.
2. Reports hearing voices talking about the baby.
3. States she has no appetite and wants to sleep all day.
4. Says she needs a refill on her sertraline (Zoloft) next week.
Answer: 2
Rationale 1:
While this may indicate postpartum blues or postpartum depression, and is not the highest
priority.
Rationale 2:
This is an indication the patient is experiencing postpartum psychosis, and is the highest
priority, because the voices might tell her to harm her baby.
Rationale 3:
This is an indication the patient is experiencing may be experiencing postpartum depression,
but is not the highest priority.
Rationale 4:
A patient on medications needs refills on time, but right now she has medication, and
therefore is not a high priority.
13) The maternal nurse educator is conducting a presentation for antepartum patients
describing the identification and care of women diagnosed with postpartum psychiatric
disorders. Which information should the maternal nurse educator include in her teaching
content?
1. Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized
by mild depression interspersed with happier feelings.
2. Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks.
3. Even if she is asymptomatic, a woman with a history of postpartum depression should be
referred to a mental health professional for counseling and biweekly visits postpartum.
4. Women with postpartum depression have a history of exposure to an extremely traumatic
personal event that involves actual or threatened death or serious injury and evokes intense
fear, helplessness, or horror.
Answer: 3
Rationale 1:
As many as 50% to 70% of mothers develop adjustment reaction with depressed mood,
which is also known as postpartum blues, or as maternal or baby blues. Unlike postpartum
depression, this condition is characterized by mild depression interspersed with happier
feelings.
Rationale 2:
Postpartum blues typically manifest as mild symptoms that are transient and self-limiting.
Postpartum depression is severe and poses major threats to the woman and the infant, as well
as to the father/partner.
Rationale 3:
Women with a history of postpartum psychosis or depression or other risk factors should be
referred to a mental health professional for counseling and biweekly visits between the
second and sixth week postpartum for evaluation.
Rationale 4:
Post-traumatic stress disorder or PTSD (also called post-traumatic stress syndrome) is
associated with exposure to an extremely traumatic event involving direct personal
experience with actual or threatened death or serious injury, and evokes a reaction of intense
fear, helplessness, or horror.
14) The charge nurse is reviewing the plan of care for maternal patients currently admitted
for postpartum care. During the course of her chart review, which intervention requires
immediate consideration for revision?
1. Daily prothrombin time (PT) measurements for coagulation assessment in a woman
receiving heparin for treatment of thrombophlebitis.
2. Use of the REEDA scale for assessment every 8 hours in the care of a patient diagnosed
with puerperal infection.
3. Misoprostol (Cytotec) administration to a patient who demonstrates uterine atony and
bleeding after receiving oxytocic medications.
4. Inserting a straight catheter to drain the overdistended bladder of a woman during the early
postpartum period of her care.
Answer: 1
Rationale 1:
Prothrombin time (PT) evaluates the anticoagulation effects of Coumadin; the effects of
heparin are assessed by way of activated partial thromboplastin time (aPTT).
Rationale 2:
The nurse should inspect the woman’s perineum every 8 to 12 hours for signs of early
infection. The REEDA scale helps the nurse remember to consider redness, edema,
ecchymosis, discharge, and approximation.
Rationale 3:
Misoprostol (Cytotec) is used to prevent and treat uterine atony after failed attempts to
control bleeding with oxytocics.
Rationale 4:
Overdistention in the early postpartum period is often managed by draining the bladder with a
straight catheter as a one-time measure.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
