Maternity Newborn and Women’s Health Nursing A Case-Based Approach 1st Edition O’Meara Test Bank.

Chapter 1 Immediate Postpartum Hemorrhage

MULTIPLE CHOICE

1. A pregnant woman is being discharged from the hospital after the placement of a cervical cerclage because of a history of recurrent pregnancy loss, secondary to an incompetent cervix. Which information regarding postprocedural care should the nurse emphasize in the discharge teaching?

a. Any vaginal discharge should be immediately reported to her health care provider.
b. The presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should c. The client will need to make arrangements for care at home, because her activity level will be restricted.
d. The client will be scheduled for a cesarean birth.
ANS: B
Nursing care should stress the importance of monitoring for the signs and symptoms of preterm labor. Vaginal bleeding needs to be reported to her primary health care provider. Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, which allows her the freedom to see her physician. Home uterine activity monitoring may be used to limit the womans need for visits and to monitor her status safely at home. The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean birth can be planned.
DIF: Cognitive Level: Apply REF: dm. 675
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. A perinatal nurse is giving discharge instructions to a woman, status postsuction, and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. What is the bestresponse by the nurse?
a.
If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you pregnancy, it would be better for you to use the most reliable method of contraception available.
b.
The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring hormone that your body produces during pregnancy. If you were to get pregnant, then it would make this cancer more difficult.
c.
If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy improve your chance of a successful pregnancy, not getting pregnant at this time is best.
d. Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.
ANS: B
Betahuman chorionic gonadotropin (beta-hCG) hormone levels are drawn for 1 year to ensure that the mole is completely gone. The chance of developing choriocarcinoma after the development of a hydatidiform mole is increased. Therefore, the goal is to achieve a zero human chorionic gonadotropin (hCG) level. If the woman were to become pregnant, then it may obscure

the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device (IUD) is acceptable.
DIF: Cognitive Level: Apply REF: dm. 679
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
3. The nurse is preparing to administer methotrexate to the client. This hazardous drug
is most often used for which obstetric complication?
a. Complete hydatidiform mole
b. Missed abortion
c. Unruptured ectopic pregnancy
d. Abruptio placentae
ANS: C
Methotrexate is an effective nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and measures less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole, for a missed abortion, or for abruptio placentae.
DIF: Cognitive Level: Apply REF: dm. 677 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
4. A 26-year-old pregnant woman, gravida 2, para 1-0-0-1, is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, which diagnostic procedure will the client most likely have performed?
a. Amniocentesis for fetal lung maturity
b. Transvaginal ultrasound for placental location
c. Contraction stress test (CST)
d. Internal fetal monitoring
ANS: B
The presence of painless bleeding should always alert the health care team to the possibility of placenta previa, which can be confirmed through ultrasonography. Amniocentesis is not performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus is presumed to have immature lungs at this gestational age, and the mother is given corticosteroids to aid in fetal lung maturity. A CST is not performed at a preterm gestational age. Furthermore, bleeding is a contraindication to a CST. Internal fetal monitoring is also contraindicated in the presence of bleeding.
DIF: Cognitive Level: Apply REF: dm. 680
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
5. A laboring woman with no known risk factors suddenly experiences spontaneous ROM. The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. No change in uterine resting tone has occurred. The fetal heart rate (FHR) begins to decline rapidly after the ROM. The nurse should suspect the possibility of what condition?
a. Placenta previa
b. Vasa previa
c. Severe abruptio placentae

d. Disseminated intravascular coagulation (DIC)
ANS: B
Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. The umbilical blood vessels thus are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the FHR without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and is considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity typically is tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as the hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome. This woman did not have any prior risk factors.
DIF: Cognitive Level: Analyze REF: dm. 684 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
6. A woman arrives for evaluation of signs and symptoms that include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination, the nurse notices an ecchymotic blueness around the womans umbilicus. What does this finding indicate?
a. Normal integumentary changes associated with pregnancy
b. Turner sign associated with appendicitis
c. Cullen sign associated with a ruptured ectopic pregnancy
d. Chadwick sign associated with early pregnancy
ANS: C
Cullen sign, the blue ecchymosis observed in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy and exhibits a brown pigmented, vertical line on the lower abdomen. Turner sign is ecchymosis in the flank area, often associated with pancreatitis. A Chadwick sign is a blue-purple cervix that may be seen during or around the eighth week of pregnancy.
DIF: Cognitive Level: Analyze REF: dm. 676
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. The nurse who elects to practice in the area of womens health must have a thorough understanding of miscarriage. Which statement regarding this condition is most accurate?
a. A miscarriage is a natural pregnancy loss before labor begins.
b. It occurs in fewer than 5% of all clinically recognized pregnancies.
c. Careless maternal behavior, such as poor nutrition or excessive exercise, can be a factor in causing a d.
If a miscarriage occurs before the 12th week of pregnancy, then it may be observed only as moderate blood loss.
ANS: D

Before the sixth week, the only evidence might be a heavy menstrual flow. After the 12th week, more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but it occurs, by definition, before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriages can be caused by a number of disorders or illnesses outside the mothers control or knowledge.

DIF: Cognitive Level: Understand REF: dm. 670
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which differential diagnosis would not be applicable for this client?
a. Placenta previa
b. Abruptio placentae
c. Spontaneous abortion
d. Cord insertion
ANS: C
Spontaneous abortion is another name for miscarriage; it occurs, by definition, early in pregnancy. Placenta previa is a well-known reason for bleeding late in pregnancy. The premature separation of the placenta (abruptio placentae) is a bleeding disorder that can occur late in pregnancy. Cord insertion may cause a bleeding disorder that can also occur late in pregnancy. DIF: Cognitive Level: Understand REF: dm. 669
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Physiologic Adaptation
9. With regard to hemorrhagic complications that may occur during pregnancy, what information is most accurate?
a. An incompetent cervix is usually not diagnosed until the woman has lost one or two pregnancies.
b. Incidences of ectopic pregnancy are declining as a result of improved diagnostic techniques.
c. One ectopic pregnancy does not affect a womans fertility or her likelihood of having a normal pregnancy d. Gestational trophoblastic neoplasia (GTN) is one of the persistently incurable gynecologic malignancies.
ANS: A
Short labors and recurring losses of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence. Because diagnostic technology is improving, more ectopic pregnancies are being diagnosed. One ectopic pregnancy places the woman at increased risk for another one. Ectopic pregnancy is a leading cause of infertility. Once invariably fatal, GTN now is the most curable gynecologic malignancy.
DIF: Cognitive Level: Understand REF: dm. 675
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. The management of the pregnant client who has experienced a pregnancy loss depends on the type of miscarriage and the signs and symptoms. While planning care for a client who desires outpatient management after a first-trimester loss, what would the nurse expect the plan to include?
a. Dilation and curettage (D&C)
b. Dilation and evacuation (D&E)
c. Misoprostol
d. Ergot products
ANS: C

Outpatient management of a first-trimester loss is safely accomplished by the intravaginal use of misoprostol for up to 2 days. If the bleeding is uncontrollable, vital signs are unstable, or signs of infection are present, then a surgical evacuation should be performed. D&C is a surgical procedure that requires dilation of the cervix and scraping of the uterine walls to remove the contents of pregnancy. This procedure is commonly performed to treat inevitable or incomplete abortion and should be performed in a hospital. D&E is usually performed after 16 weeks of pregnancy. The cervix is widely dilated, followed by removal of the contents of the uterus. Ergot products such as Methergine or Hemabate may be administered for excessive bleeding after miscarriage.

DIF: Cognitive Level: Apply REF: dm. 672 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
11. Which laboratory marker is indicative of DIC?
a. Bleeding time of 10 minutes

b. Presence of fibrin split products c. Thrombocytopenia
d. Hypofibrinogenemia
ANS: B

Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys vasculature. Bleeding time in DIC is normal. Low platelets may occur but are not indicative of DIC because they may be the result from other coagulopathies. Hypofibrinogenemia occurs with DIC.

DIF: Cognitive Level: Remember REF: dm. 684
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
12. When is a prophylactic cerclage for an incompetent cervix usually placed (in weeks of gestation)?
a. 12 to 14
b. 6 to 8
c. 23 to 24
d. After 24
ANS: A
A prophylactic cerclage is usually placed at 12 to 14 weeks of gestation. The cerclage is electively removed when the woman reaches 37 weeks of gestation or when her labor begins. Six to 8 weeks of gestation is too early to place the cerclage. Cerclage placement is offered if the cervical length falls to less than 20 to 25 mm before 23 to 24 weeks. Although no consensus has been reached, 24 weeks is used as the upper gestational age limit for cerclage placement.
DIF: Cognitive Level: Apply REF: dm. 674 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
13. In caring for an immediate postpartum client, the nurse notes petechiae and oozing from her intravenous (IV) site. The client would be closely monitored for which clotting disorder?
a. DIC
b. Amniotic fluid embolism (AFE)
c. Hemorrhage
d. HELLP syndrome
ANS: A
The diagnosis of DIC is made according to clinical findings and laboratory markers. A physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the

womans arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the postpartum client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP syndrome is not a clotting disorder, but it may contribute to the clotting disorder DIC.

DIF: Cognitive Level: Understand REF: dm. 685 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
14. In caring for the woman with DIC, which order should the nurse anticipate?
a. Administration of blood

b. Preparation of the client for invasive hemodynamic monitoring c. Restriction of intravascular fluids
d. Administration of steroids
ANS: A

Primary medical management in all cases of DIC involves a correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be initially ordered in a client with DIC because it could contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

DIF: Cognitive Level: Apply REF: pp. 685-686 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
15. A woman arrives at the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?
a. Incomplete
b. Inevitable
c. Threatened
d. Septic
ANS: C
A woman with a threatened abortion has spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would have heavy bleeding, mild-to-severe cramping, and cervical dilation. An inevitable abortion demonstrates the same symptoms as an incomplete abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic abortion has malodorous bleeding and typically a dilated cervix.
DIF: Cognitive Level: Understand REF: dm. 670 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
16. In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio placentae?
a. Bleeding
b. Intense abdominal pain
c. Uterine activity
d. Cramping
ANS: B

Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.
DIF: Cognitive Level: Understand REF: dm. 683 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Physiologic Integrity
17. Which maternal condition always necessitates delivery by cesarean birth?
a. Marginal placenta previa
b. Complete placenta previa
c. Ectopic pregnancy
d. Eclampsia
ANS: B
In complete placenta previa, the placenta completely covers the cervical os. A cesarean birth is the acceptable method of delivery. The risk of fetal death occurring is due to preterm birth. If the previa is marginal (i.e., 2 cm or greater away from the cervical os), then labor can be attempted. A cesarean birth is not indicated for an ectopic pregnancy. Labor can be safely induced if the eclampsia is under control.
DIF: Cognitive Level: Understand REF: dm. 681
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
18. What is the correct definition of a spontaneous termination of a pregnancy (abortion)?
a. Pregnancy is less than 20 weeks.
b. Fetus weighs less than 1000 g.
c. Products of conception are passed intact.
d. No evidence exists of intrauterine infection.
ANS: A
An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete and may be caused by many problems, one being intrauterine infection.
DIF: Cognitive Level: Remember REF: dm. 669
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
19. What is the correct terminology for an abortion in which the fetus dies but is retained within the uterus?
a. Inevitable abortion
b. Missed abortion
c. Incomplete abortion
d. Threatened abortion
ANS: B
Missed abortion refers to the retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion, the woman has cramping and bleeding but no cervical dilation.
DIF: Cognitive Level: Remember REF: dm. 670
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
20. What condition indicates concealed hemorrhage when the client experiences abruptio placentae?
a. Decrease in abdominal pain

b. Bradycardia
c. Hard, boardlike abdomen
d. Decrease in fundal height
ANS: C
Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. Abdominal pain may increase. The client will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height increases.
DIF: Cognitive Level: Analyze REF: dm. 683
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
21. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?
a. Assessing FHR and maternal vital signs
b. Performing a venipuncture for hemoglobin and hematocrit levels
c. Placing clean disposable pads to collect any drainage
d. Monitoring uterine contractions
ANS: A
Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check the well-being of both the mother and the fetus. The blood levels can be obtained later. Assessing future bleeding is important; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not a top priority.
DIF: Cognitive Level: Apply REF: dm. 681
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 22. Which order should the nurse expect for a client admitted with a threatened abortion?
a. Bed rest
b. Administration of ritodrine IV
c. Nothing by mouth (nil per os [NPO])
d. Narcotic analgesia every 3 hours, as needed
ANS: A
Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. Having the woman placed on NPO is unnecessary. At times, dehydration may produce contractions; therefore, hydration is important. Narcotic analgesia will not decrease the contractions and may mask the severity of the contractions.
DIF: Cognitive Level: Understand REF: pp. 671-672 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
23. Which finding on a prenatal visit at 10 weeks of gestation might suggest a hydatidiform mole?
a. Complaint of frequent mild nausea
b. Blood pressure of 120/80 mm Hg
c. Fundal height measurement of 18 cm
d. History of bright red spotting for 1 day, weeks ago
ANS: C
The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased

production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the clients history, bleeding is normally described as brownish.
DIF: Cognitive Level: Analyze REF: dm. 678
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Which information assists the nurse in developing the plan of care?

a. Bed rest and analgesics are the recommended treatment.
b. She will be unable to conceive in the future.
c. A D&C will be performed to remove the products of conception.
d. Hemorrhage is the primary concern.
ANS: D
Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture to prevent hemorrhaging. If the tube must be removed, then the womans fertility will decrease; however, she will not be infertile. A D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.
DIF: Cognitive Level: Apply REF: dm. 676 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. A client who has undergone a D&C for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that her vital signs are stable, that bleeding has been controlled, and that the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, what information should discharge teaching include? (Select all that apply.) a. Iron supplementation
b. Resumption of intercourse at 6 weeks postprocedure
c. Referral to a support group, if necessary
d. Expectation of heavy bleeding for at least 2 weeks
e. Emphasizing the need for rest
ANS: A, C, E
The woman should be advised to consume a diet high in iron and protein. For many women, iron supplementation also is necessary. The nurse should acknowledge that the client has experienced a loss, however early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure, including tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her health care provider.
DIF: Cognitive Level: Apply REF: dm. 672
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.)
a. Chromosomal abnormalities
b. Infections
c. Endocrine imbalance
d. Systemic disorders
e. Varicella

ANS: A, C, D, E
Infections are not a common cause of early miscarriage. At least 50% of pregnancy losses result from chromosomal abnormalities. Endocrine imbalances such as hypothyroidism or diabetes are also possible causes for early pregnancy loss. Other systemic disorders that may contribute to pregnancy loss include lupus and genetic conditions. Although infections are not a common cause of early miscarriage, varicella infection in the first trimester has been associated with pregnancy loss.
DIF: Cognitive Level: Remember REF: dm. 669
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. The reported incidence of ectopic pregnancy has steadily risen over the past 2 decades. Causes include the increase in sexually transmitted infections (STIs) accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse suspects that a client has early signs of ectopic pregnancy. The nurse should be observing the client for which signs or symptoms? (Select all that apply.)
a. Pelvic pain
b. Abdominal pain
c. Unanticipated heavy bleeding
d. Vaginal spotting or light bleeding
e. Missed period
ANS: A, B, D, E
A missed period or spotting can be easily mistaken by the client as an early sign of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage, which may progress to hypovolemic shock with minimal or even no external bleeding. In approximately one half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.
Chapter 2 Later Postpartum Hemorrhage
1. What is the first sign of hypovolemic shock from postpartum hemorrhage?
a. Cold, clammy skin
b. Tachycardia
c. Hypotension
d. Decreased urinary output
ANS: B
Tachycardia is usually the first sign of inadequate blood volume.
2. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected?
a. Teach the patient how to massage the abdomen and then get help.
b. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
c. Begin massaging the fundus while another person notifies the physician.
d. Ask the patient to void and reassess fundal tone and location.
ANS: C
When the uterus is boggy, the nurse should immediately massage it until it becomes firm.
3. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and
sore breasts. What does the nurse suspect from these symptoms?

a. Phlebitis
b. Puerperal infection
c. Late postpartum hemorrhage
d. Mastitis
ANS: A
The complaints related to the leg are indicative of phlebitis. The other signs are normal in
the postpartum patient.
5. Which statement indicates to the nurse on a postpartum home visit that the patient
understands the signs of late postpartum hemorrhage?
a. My discharge would change to red after it has been pink or white.
b. If I have a postpartum hemorrhage, I will have severe abdominal pain.
c. I should be alert for an increase in bright red blood.
d. I would pass a large clot that was retained from the placenta.
ANS: A
When the nurse teaches the postpartum woman about normal changes in lochia, it is
important to explain that a return to red bleeding after it has changed to pink or white
may indicate a late postpartum hemorrhage.
6. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.)
a. Hypertension
b. Blood clotting disorders
c. Anemia
d. Infection
e. Postpartum hemorrhage
ANS: B, C, D, E
Hypertension is not a cause for postpartum shock; all the other options can cause shock.
Chapter 3 Gestational Diabetes, Deep Vein Thrombosis, and Postpartum Pulmonary
Embolism
MULTIPLE CHOICE
1. Preconception counseling is critical in the safe management of diabetic pregnancies. Which complication is commonly associated with poor glycemic control before and during early pregnancy?
a. Frequent episodes of maternal hypoglycemia
b. Congenital anomalies in the fetus
c. Hydramnios
d. Hyperemesis gravidarum
ANS: B
Preconception counseling is particularly important since strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risk of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormonal changes and the effects on insulin production and use. Hydramnios occurs approximately 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically, it is observed in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.
DIF: Cognitive Level: Understand REF: dm. 687 TOP: Nursing Process: Planning

MSC: Client Needs: Physiologic Integrity
2. During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective?
a. I will need to eat 600 more calories per day because I am pregnant.
b. I can continue with the same diet as before pregnancy as long as it is well balanced.
c. Diet and insulin needs change during pregnancy.
d. I will plan my diet based on the results of urine glucose testing.
ANS: C
Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs may double or even quadruple. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Energy needs are usually calculated on the basis of 30 to 35 calories per kilogram of ideal body weight. Dietary management during a diabetic pregnancy must be based on blood, not urine, glucose changes. DIF: Cognitive Level: Analyze REF: dm. 689 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiologic Integrity
3. Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the client mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. This fetus is at the greatest risk for which condition?
a. Macrosomia
b. Congenital anomalies of the central nervous system
c. Preterm birth
d. Low birth weight
ANS: A
Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this fetus.
DIF: Cognitive Level: Understand REF: dm. 690
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
4. A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. Which nursing diagnosis is most appropriate for the client at this time?
a. Deficient fluid volume
b. Imbalanced nutrition: less than body requirements
c. Imbalanced nutrition: more than body requirements
d. Disturbed sleep pattern
ANS: B
This clients clinical cues include weight loss, which supports a nursing diagnosis of Imbalanced

nutrition: less than body requirements. No clinical signs or symptoms support a nursing diagnosis of deficient fluid volume. This client reports weight loss, not weight gain. Although the client reports nervousness, the most appropriate nursing diagnosis, based on the clients other clinical symptoms, is Imbalanced nutrition: less than body requirements.
DIF: Cognitive Level: Analyze REF: dm. 706 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
5. A client with maternal phenylketonuria (PKU) has come to the obstetrical clinic to begin prenatal care. Why would this preexisting condition result in the need for closer monitoring during pregnancy?
a. PKU is a recognized cause of preterm labor.
b. The fetus may develop neurologic problems.
c. A pregnant woman is more likely to die without strict dietary control.
d. Women with PKU are usually mentally handicapped and should not reproduce.
ANS: B
Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of an uncertain cause, or who have given birth to microcephalic infants.
DIF: Cognitive Level: Understand REF: dm. 707
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. The nurse who is caring for a woman hospitalized for hyperemesis gravidarum would expect the initial treatment to involve what?
a. Corticosteroids to reduce inflammation
b. Intravenous (IV) therapy to correct fluid and electrolyte imbalances
c. Antiemetic medication, such as pyridoxine, to control nausea and vomiting
d. Enteral nutrition to correct nutritional deficits
ANS: B
Initially, the woman who is unable to down clear liquids by mouth requires IV therapy to correct fluid and electrolyte imbalances. Corticosteroids have been successfully used to treat refractory hyperemesis gravidarum, but they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic medication. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation but is not the initial treatment for this client.
DIF: Cognitive Level: Apply REF: dm. 705
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
7. In terms of the incidence and classification of diabetes, which information should the nurse keep in mind when evaluating clients during their ongoing prenatal appointments?
a. Type 1 diabetes is most common.
b. Type 2 diabetes often goes undiagnosed.
c. GDM means that the woman will receive insulin treatment until 6 weeks after birth.
d. Type 1 diabetes may become type 2 during pregnancy.
ANS: B
Type 2 diabetes often goes undiagnosed because hyperglycemia gradually develops and is often

not severe. Type 2, sometimes called adult-onset diabetes, is the most common type of diabetes. GDM refers to any degree of glucose intolerance first recognized during pregnancy; insulin may or may not be needed. People do not go back and forth between type 1 and type 2 diabetes.
DIF: Cognitive Level: Apply REF: dm. 688

TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. A number of metabolic changes occur throughout pregnancy. Which physiologic adaptation of pregnancy will influence the nurses plan of care?
a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own.
b.
Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because consuming more sugar.
c.
During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant glucose for the fetus.
d. Maternal insulin requirements steadily decline during pregnancy.
ANS: C
Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own around the 10th week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.
DIF: Cognitive Level: Understand REF:
MSC: Client Needs: Physiologic Integrity
9. Which statement concerning the complication of maternal diabetes is the most accurate?
a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
b. Hydramnios occurs approximately twice as often in diabetic pregnancies than in nondiabetic pregnancies.
c. Infections occur about as often and are considered about as serious in both diabetic and nondiabetic d. Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being.
ANS: A
Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.
DIF: Cognitive Level: Understand REF: dm. 691 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
10. Which statement regarding the laboratory test for glycosylated hemoglobin Alc is correct?
a.
The laboratory test for glycosylated hemoglobin Alc is performed for all pregnant women, not only to have diabetes.
b. This laboratory test is a snapshot of glucose control at the moment.
c. This laboratory test measures the levels of hemoglobin Alc, which should remain at less than 7%.
d. This laboratory test is performed on the womans urine, not her blood.

ANS: C
Hemoglobin Alc levels greater than 7% indicate an elevated glucose level during the previous 4 to 6 weeks. This extra laboratory test is for diabetic women and defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are performed on the blood.
DIF: Cognitive Level: Understand REF: dm. 692 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
11. A new mother with a thyroid disorder has come for a lactation follow-up appointment. Which thyroid disorder is a contraindication for breastfeeding?
a. Hyperthyroidism
b. PKU
c. Hypothyroidism
d. Thyroid storm
ANS: B
PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine and therefore should elect not to breastfeed. A woman with either hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism and is not a contraindication to breastfeeding.
DIF: Cognitive Level: Understand REF: dm. 708 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
12. An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to assist in planning adequate care. What is the most appropriate diagnosis at this time?
a. Risk for injury, to the fetus related to birth trauma
b. Deficient knowledge, related to diabetic pregnancy management
c. Deficient knowledge, related to insulin administration
d. Risk for injury, to the mother related to hypoglycemia or hyperglycemia
ANS: B
Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears more concerned about changes to her social life than adopting a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come later in the pregnancy. At this time, the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made and may not participate in the plan of care until understanding takes place.
DIF: Cognitive Level: Analyze REF: dm. 693 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity
13. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates?
a. 75 mg/dl before lunch. This is low; better eat now.
b. 115 mg/dl 1 hour after lunch. This is a little high; maybe eat a little less next time.

c. 115 mg/dl 2 hours after lunch. This is too high; it is time for insulin.
d. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.
ANS: D
50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.
DIF: Cognitive Level: Apply REF: dm. 693 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
14. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
a. Hypoglycemia
b. Hypercalcemia
c. Hypobilirubinemia
d. Hypoinsulinemia
ANS: A
The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth, and large amounts of bilirubin are released into the neonates circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, hyperinsulinemia develops in the neonate.
DIF: Cognitive Level: Apply REF: dm. 698 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
15. Which preexisting factor is known to increase the risk of GDM?
a. Underweight before pregnancy
b. Maternal age younger than 25 years
c. Previous birth of large infant
d. Previous diagnosis of type 2 diabetes mellitus
ANS: C
A previous birth of a large infant suggests GDM. Obesity (body mass index [BMI] of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years is not generally at risk for GDM. The person with type 2 diabetes mellitus already has diabetes and thus will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.
DIF: Cognitive Level: Understand REF: dm. 699
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
16. Which physiologic alteration of pregnancy most significantly affects glucose metabolism?
a. Pancreatic function in the islets of Langerhans is affected by pregnancy.
b. Pregnant women use glucose at a more rapid rate than nonpregnant women.

c. Pregnant women significantly increase their dietary intake.
d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.
ANS: D
Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin is also broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.
DIF: Cognitive Level: Understand REF: dm. 699
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
17. To manage her diabetes appropriately and to ensure a good fetal outcome, how would the pregnant woman with diabetes alter her diet?
a. Eat six small equal meals per day.
b. Reduce the carbohydrates in her diet.
c. Eat her meals and snacks on a fixed schedule.
d. Increase her consumption of protein.
ANS: C
Having a fixed meal schedule will provide the woman and the fetus with a steady blood sugar level, provide a good balance with insulin administration, and help prevent complications. Having a fixed meal schedule is more important than the equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.
DIF: Cognitive Level: Understand REF: dm. 693 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A serious but uncommon complication of undiagnosed or partially treated hyperthyroidism is a thyroid storm, which may occur in response to stress such as infection, birth, or surgery. What are the signs and symptoms of this emergency disorder? (Select all that apply.)
a. Fever
b. Hypothermia
c. Restlessness
d. Bradycardia
e. Hypertension
ANS: A, C
Fever, restlessness, tachycardia, vomiting, hypotension, and stupor are symptoms of a thyroid storm. Fever, not hypothermia; tachycardia, not bradycardia; and hypotension, not hypertension, are symptoms of thyroid storm.
DIF: Cognitive Level: Analyze REF: dm. 706
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Because severe hypothyroidism is associated with infertility and miscarriage, it is not often seen in pregnancy. Regardless of this fact, the nurse should be aware of the characteristic symptoms of hypothyroidism. Which do they include? (Select all that apply.)
a. Hot flashes

b. Weight loss
c. Lethargy
d. Decrease in exercise capacity
e. Cold intolerance
ANS: C, D, E
Symptoms include weight gain, lethargy, decrease in exercise capacity, and intolerance to cold. Other presentations might include constipation, hoarseness, hair loss, and dry skin. Thyroid supplements are used to treat hyperthyroidism in pregnancy.
DIF: Cognitive Level: Understand REF: dm. 707
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. What do these complications include? (Select all that apply.)
a. Atherosclerosis
b. Retinopathy
c. Intrauterine fetal death (IUFD)
d. Nephropathy
e. Neuropathy
f. Autonomic neuropathy
ANS: A, B, D, E
These structural changes will most likely affect a variety of systems, including the heart, eyes, kidneys, and nerves. IUFD (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.
DIF: Cognitive Level: Understand REF: dm. 688 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
COMPLETION
1. Achieving and maintaining euglycemia are the primary goals of medical therapy for the pregnant woman with diabetes. These goals are achieved through a combination of diet, insulin, exercise, and blood glucose monitoring. The target blood glucose levels 1 hour after a meal should be _____________.
ANS:
110 to 129 mg/dl
Target levels of blood glucose during pregnancy are lower than nonpregnant values. Accepted fasting levels are between 60 and 99 mg/dl, and 1-hour postmeal levels should be between 110 to 129 mg/dl. Two-hour postmeal levels should be 120 mg/dl or less.
DIF: Cognitive Level: Apply REF: dm. 693
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance MATCHING
The nurse is preparing to teach an antepartum client with GDM the correct method of administering an intermediate-acting insulin, such as neutral protamine Hagedorn (NPH), with a

short-acting insulin (regular). In the correct order from 1 through 6, match the step number with the action needed to teach the client self-administration of this combination of insulin.
a. Without adding air, withdraw the correct dose of NPH insulin.
b. Gently rotate the insulin to mix it, and wipe the stopper.

c. Inject air equal to the dose of NPH insulin into the vial, and remove the syringe.
d. Inject air equal to the dose of regular insulin into the vial, and withdraw the medication.
e. Check the insulin bottles for the expiration date.
f. Wash hands.
1. Step 1
2. Step 2
3. Step 3
4. Step 4
5. Step 5
6. Step 6
1. ANS: F DIF: Cognitive Level: Apply REF: dm. 694
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type.
2. ANS: E DIF: Cognitive Level: Apply REF: dm. 694
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type.
3. ANS: B DIF: Cognitive Level: Apply REF: dm. 694
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type.
4. ANS: C DIF: Cognitive Level: Apply REF: dm. 694
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type.

5. ANS: D DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation