Preview Extract
Chapter 9
1) The nurse is auscultating fetal heart tones in a patient who is 37 weeks' gestation. While in
a supine position, the patient states, “I’m getting lightheaded and dizzy, and I feel clammy.”
Which of the following nursing actions is most appropriate?
1. Place a wedge beneath the patient's right hip.
2. Prepare for administration of packed red blood cells (PRBCs).
3. Help the patient turn onto her right side.
4. Administer supplemental oxygen.
Answer: 1
Rationale 1:
The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which
compression of the vena cava by the uterus reduces right atrial blood flow. Signs and
symptoms include decreased blood pressure, dizziness, pallor, and clamminess. Appropriate
interventions include having the woman lie on her left side, or placing a pillow or wedge
under her right hip as she lies in a supine position.
Rationale 2:
The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which
compression of the vena cava by the uterus reduces right atrial blood flow. Repositioning the
patient onto her left side or placing a pillow or wedge under her right hip are appropriate
interventions.
Rationale 3:
The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which
compression of the vena cava by the uterus reduces right atrial blood flow. Positioning the
patient on her right side would likely exacerbate the reduction in right atrial blood flow.
Rationale 4:
The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which
compression of the vena cava by the uterus reduces right atrial blood flow. Priority
interventions include repositioning the patient onto her left side, or placing a pillow or wedge
under her right hip.
2) The patient with a normal pre-pregnancy weight asks why she has been told to gain 25–35
pounds during her pregnancy, but her underweight friend was told to gain more weight. The
nurse should tell the patient that recommended weight gain during pregnancy should be:
1. 25–35 pounds, regardless of a patient’s pre-pregnancy weight.
2. More than 25–35 pounds for an overweight patient.
3. More than 25–35 pounds for an underweight woman.
4. The same for a normal-weight woman as for an overweight woman.
Answer: 3
Rationale 1:
Pre-pregnancy weight determines the recommended weight gain during pregnancy. Women
of normal weight should gain 25–35 pounds during pregnancy for optimal fetal outcome.
Rationale 2:
Overweight women should gain 15–25 pounds during pregnancy.
Rationale 3:
Underweight women are encouraged to gain 28-40 pounds during pregnancy.
Rationale 4:
Overweight women should gain 15–25 pounds during pregnancy.
3) The nurse is reviewing the assessment findings of a patient who is 35 weeks' gestation.
Which of the following data suggests the need for further investigation?
1. Melasma gravidarum
2. Pseudoanemia
3. Funic souffle
4. Glycosuria
Answer: 4
Rationale 1:
Facial chloasma or melasma gravidarum (also known as the “mask of pregnancy”) is a
harmless darkening of the skin over the cheeks, nose, and forehead that sometimes
accompanies pregnancy.
Rationale 2:
Physiologic anemia of pregnancy or pseudoanemia is common during pregnancy and is an
expected finding.
Rationale 3:
Funic souffle is a normal assessment finding associated with the pulsing of blood through the
umbilical cord.
Rationale 4:
Glycosuria (glucose in the urine) during pregnancy may be normal or may indicate
gestational diabetes, so it always warrants further testing.
4) The patient in the prenatal clinic tells the nurse that she is sure that she is pregnant because
she has not had a menstrual cycle for three months, and her breasts are getting bigger. What
response by the nurse is best?
1. “Lack of menses and breast enlargement are presumptive signs of pregnancy.”
2. “The changes you are describing are definitely indicators that you are pregnant.”
3. “Lack of menses can be caused by many things. We need to do a pregnancy test.”
4. “Breast and menstrual changes are positive signs of pregnancy. Congratulations.”
Answer: 3
Rationale 1:
Although this is true, amenorrhea and breast enlargement also can be caused by weight gain
and other conditions. A pregnancy test is needed to determine whether the patient is pregnant.
Rationale 2:
This statement is false because amenorrhea and breast enlargement are presumptive signs of
pregnancy because they can be caused by other conditions.
Rationale 3:
This is a true statement and addresses that these changes could be caused by things other than
pregnancy.
Rationale 4:
This statement is false because amenorrhea and breast enlargement are presumptive signs. It
is too early to determine if congratulations are in order.
5) The nurse has completed a presentation for newly-pregnant women about the changes of
pregnancy. Which participant's statement reflects accurate comprehension of the
information?
1. "A positive Goodell's sign is a probable change of pregnancy."
2. "Three positive pregnancy tests in a one week period is considered to be a positive change
of pregnancy."
3. “Uterine souffle is a positive change of pregnancy.”
4. “Changes in the pelvic organs are presumptive signs of pregnancy.”
Answer: 1
Rationale 1:
A positive Goodell's sign can be objectively identified but may also be caused by conditions
other than pregnancy; therefore, it is considered to be a probable change of pregnancy.
Rationale 2:
Because other conditions may cause elevated hCG, pregnancy tests are considered probable
changes of pregnancy.
Rationale 3:
Because uterine souffle can be objectively identified but may be caused by conditions other
than pregnancy, it is considered to be a probable change of pregnancy.
Rationale 4:
Changes in the pelvic organs can be objectively identified; however, because some pelvic
organ changes may be associated with conditions other than pregnancy, they are considered
to be probable changes of pregnancy.
6) A patient who is experiencing her first pregnancy has just completed the initial prenatal
examination with a certified nurse–midwife. Which statement indicates that the patient has a
correct understanding of her condition?
1. “Because we heard the baby’s heartbeat, I am undoubtedly pregnant.”
2. “Since I haven’t felt the baby move yet, we don’t know if I’m pregnant.”
3. “My last period was two months ago, which means I’m two months along.”
4. “The increased size of my uterus means that I am finally pregnant.”
Answer: 1
Rationale 1:
Hearing the fetal heart rate is a positive or diagnostic change of pregnancy.
Rationale 2:
Fetal movement is a presumptive or subjective change of pregnancy. Absence or presence of
the sensation of fetal movement is not a conclusive indicator of pregnancy status.
Rationale 3:
Amenorrhea is a presumptive or subjective change and does not conclusively verify
pregnancy status.
Rationale 4:
Increased uterine size is a probable or objective change and does not conclusively verify
pregnancy status.
7) The adolescent patient reports to the clinic nurse that her period is late but that her home
pregnancy test is negative. Which response is most appropriate?
1. “This means you are not pregnant.”
2. “You might be pregnant, but it might be too early for your home test to be accurate.”
3. “We don’t trust home tests. Come to the clinic for a blood test.”
4. “Most people don’t use the tests correctly. Did you read the instructions?”
Answer: 2
Rationale 1:
Although this might be true, this is not the best response because the pregnancy may not yet
be detectable through use of a urine pregnancy test.
Rationale 2:
This is an accurate and appropriate response. Most home pregnancy tests have low false
positive rates, but the false negative rate is slightly higher. Repeating the test in one week is
recommended.
Rationale 3:
This statement is not therapeutically worded. Additionally, this statement is not true because
home pregnancy tests are quite simple to use and quite accurate. A clinic pregnancy test is
usually a urine test. Blood tests are more invasive and more expensive.
Rationale 4:
This response does not address the issues presented in the patient’s statement.
8) A 28-year-old patient who is pregnant with her first child reports increased dental caries
(cavities) since becoming pregnant. How should the nurse explain the likely cause for this
change?
1. “When a woman is pregnant, her teeth lose calcium and she is more susceptible to getting
cavities.”
2. “It may be necessary to pay extra attention to dental care while you’re pregnant, especially
if you’re vomiting frequently.”
3. “Each woman experiences changes that affect her teeth while she’s pregnant.”
4. “During pregnancy, tooth enamel softens and the woman is more susceptible to getting
cavities.”
Answer: 2
Rationale 1:
No demonstrable changes occur in the teeth of pregnant women. The dental caries that
sometimes accompany pregnancy are probably caused by inadequate oral hygiene and dental
care, especially if the woman has problems with bleeding gums or nausea and vomiting.
Rationale 2:
The dental caries that sometimes accompany pregnancy are probably caused by inadequate
oral hygiene and dental care, especially if the woman has problems with bleeding gums or
nausea and vomiting.
Rationale 3:
No demonstrable changes occur in the teeth of pregnant women.
Rationale 4:
The dental caries that sometimes accompany pregnancy are probably caused by inadequate
oral hygiene and dental care, especially if the woman has problems with bleeding gums or
nausea and vomiting.
9) A patient at 30 weeks’ gestation is tearful at the time of her follow-up visit. She tells the
prenatal clinic nurse she is excited to finally become a mother and that she has been thinking
about what kind of parent she will be. However, she is upset because her mother has told her
that she doesn’t want to be a grandmother because she doesn’t feel old enough. Meanwhile,
the patient’s husband has said that the pregnancy doesn’t feel real to him yet and that he will
become excited when the baby is actually here. What is the most likely explanation for what
is happening within this family?
1. Her husband will not attach with this child and will not be a good father.
2. Her mother is rejecting the role of grandparent and will not help out.
3. The patient is not progressing through the developmental tasks of pregnancy.
4. Each family member is adjusting to the role change at his own pace.
Answer: 4
Rationale 1:
The husband’s statement is quite common. Partners often feel that a pregnancy isn’t real to
them because they are not experiencing any of the physical changes associated with
pregnancy.
Rationale 2:
Adaptation to the role of grandparent is another life task that takes time. Younger
grandparents often have busy and full lives and view grandparenthood as a time for elderly
people who are retired and slowed down. The family will form a view of grandparenthood
within this family, in a way that works for them.
Rationale 3:
This is a false statement. The patient is at the stage of seeking acceptance of this child by
others, which first will be her partner and other family members.
Rationale 4:
This is a true statement. When the other family members are at different stages of adjustment
to the pregnancy, conflict can ensue.
10) The partner of a pregnant patient at 16 weeks’ gestation accompanies her to the clinic.
The partner tells you that the baby just doesn’t seem real to him, and he’s having a hard time
relating to his partner’s fatigue and food aversions. Which of the following statements would
be best for the nurse to make?
1. “If you would concentrate harder, you’d be aware of the reality of this pregnancy.”
2. “My husband had no problem with this. What was your childhood like?”
3. “You might need professional psychological counseling. Ask your physician.”
4. “Many men feel this way. Feeling the baby move will help make it real.”
Answer: 4
Rationale 1:
Ambivalence is common among partners, especially prior to either seeing the baby on
ultrasound or feeling the baby kick and move.
Rationale 2:
The ambivalence and disbelief occur across all socioeconomic groups, in both partners who
were fathered well and those who grew up without a father.
Rationale 3:
This reaction is not indicative of psychological pathology.
Rationale 4:
Kicking and ultrasound visualization are concrete evidence of the baby’s existence and often
are turning points in acceptance for partners.
11) A 20-year-old patient who is at 10 weeks’ gestation is preparing for her first prenatal
visit. She confides, “This pregnancy was unplanned. I’m not sure if I want to be pregnant or
not. I haven’t even told my boyfriend I’m pregnant. And I haven’t decided if I’m going to
continue the pregnancy.” Which of the following statements should the nurse make next?
1. “It’s really unusual for a pregnant woman to feel this way early in the pregnancy.”
2. “These thoughts are because your mother died when you were four years old.”
3. “You should go to a pregnancy support group to be a good mother.”
4. “It’s common to feel ambiguous about pregnancy in the first trimester.”
Answer: 4
Rationale 1:
Fathers might not be told immediately about the diagnosis of pregnancy.
Rationale 2:
Loss of the patient’s own mother at a young age would not affect the occurrence of
ambivalence in the first trimester.
Rationale 3:
No psychopathology is present, so a support group is not indicated.
Rationale 4:
Ambivalence toward the pregnancy is very common in the first trimester.
12) A 25-year-old woman is in the second trimester of her pregnancy. During the interview,
you ask her partner what changes they have noticed during the pregnancy. Which of the
following answers would indicate a typical response to pregnancy?
1. “She has been more tense and anxious than usual, and she is not sleeping well.”
2. “She daydreams about what kind of parent she is going to be.”
3. “I haven’t noticed anything. I just found out she was pregnant.”
4. “She has been having dreams at night about misplacing the baby.”
Answer: 2
Rationale 1:
During the third trimester, the woman typically experiences more anxiety and tension, as well
as increased discomfort and insomnia.
Rationale 2:
The second trimester usually brings increased introspection and consideration of how she will
parent.
Rationale 3:
In the first trimester, pregnant women usually tell their partners of the pregnancy, explore
their relationship with their mother, and think about their own role as a mother.
Rationale 4:
The needs of the newborn typically are not considered until the third trimester, at which time
dreams of misplacing the baby or being unable to get to the baby also may be common.
13) A patient who is at 14 weeks’ gestation is in the clinic for a regular prenatal visit. The
patient is accompanied by her mother. The patient’s mother states that she is very uncertain
about how to be a good grandmother to this baby, due to working full time and being so busy.
The patient’s mother notes that her own grandmother was retired and was always available
when needed by a grandchild. The best response to this concern would be:
1. “Don’t worry. You’ll be a wonderful grandmother. It will all work out fine.”
2. “Grandmothers are supposed to be available. You should retire from your job.”
3. “As long as there is another grandmother available, you don’t have to worry.”
4. “How do you envision your role as grandmother?”
Answer: 4
Rationale 1:
Casual and/or false reassurance is not appropriate. Effective therapeutic communication
requires supportive, nonjudgmental exploration of the patient’s concerns.
Rationale 2:
Assignment of guilt is not appropriate. Effective therapeutic communication requires
supportive, nonjudgmental exploration of the patient’s concerns
Rationale 3:
Minimizing a patient’s concern is not appropriate. Effective therapeutic communication
requires supportive, nonjudgmental exploration of the patient’s concerns.
Rationale 4:
Supportive, nonjudgmental exploration of the patient’s concerns is one component of
therapeutic communication and is appropriate.
14) The labor and delivery nurse is talking with a patient who is expected to deliver her baby
within the next several hours. The patient and her husband are Lebanese immigrants.
During conversation, the nurse asks the couple if they have chosen a name for their baby. The
patient's husband explains that their Muslim beliefs require that they choose the baby's name
after the delivery, as it is God's will whether or not the baby will be born. Which nursing
response is appropriate?
1. "Thank you for explaining that to me. By sharing your cultural beliefs with me, you're
helping me to provide you with the best possible care."
2. "In the United States, you can feel free to choose your baby's name prior to the delivery."
3. "We have a very low rate of complications at this facility."
4. "Are you afraid your baby will not live?"
Answer: 1
Rationale 1:
The identification of cultural values is useful in planning and providing culturally sensitive
care.
Rationale 2:
It is neither realistic nor appropriate to assume that people of another culture will
automatically abandon their ways and adopt the practices of a dominant culture.
Rationale 3:
The patient's husband is describing the application of a culturally-based belief, not a concern
about complications.
Rationale 4:
The patient's husband is describing the application of a culturally-based belief, not a fearbased concern.
15) The nurse is presenting an in-service to nursing staff regarding the provision of culturally
competent patient care. Which statement should the nurse include in the presentation?
1. "Many immigrants to a new country will adopt the beliefs and practices of the dominant
culture."
2. "Developed countries are becoming increasingly more ethnically diverse."
3. "The rituals and customs of a group reflect the values of the dominant culture."
4. "Identification of cultural values is a task that is unrelated to providing culturally sensitive
care."
Answer: 2
Rationale 1:
It is not realistic or appropriate to assume that people of another culture will automatically
abandon their ways and adopt the practices of the dominant culture.
Rationale 2:
In many developed countries such as the United States, Canada, England, Germany and so
forth, populations are becoming more and more ethnically diverse as the number of
immigrants continues to grow.
Rationale 3:
The rituals and customs of a group are a reflection of the group’s values.
Rationale 4:
The identification of cultural values is useful in planning and providing culturally sensitive
care.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
