Introduction to Maternity And Pediatric Nursing, 7th Edition by Gloria Leifer -Test Bank

Introduction to Maternity And Pediatric Nursing, 7th Edition by Gloria Leifer -Test Bank

 

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Sample Questions Are Posted Below

 

Chapter 05: Nursing Care of Women with Complications During Pregnancy

 

MULTIPLE CHOICE

 

1. A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness?

a.	Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
b.	Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
c.	Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
d.	The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.

 

 

ANS:  B

Dehydration and electrolyte imbalances result from persistent nausea and vomiting associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 79 | Page 82

OBJ:   4                    TOP:   Hyperemesis

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

2. A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing some tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms?

a.	Inevitable abortion
b.	Incomplete abortion
c.	Complete abortion
d.	Missed abortion

 

 

ANS:  B

Signs and symptoms of an incomplete abortion are similar to those of an inevitable abortion, but some tissue is passed.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 84, Table 5-2 | Page 82, Figure 5-2

OBJ:   4                    TOP:   Incomplete Abortion

KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

3. The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse?

a.	“There is usually something wrong with the fetus when this happens early in pregnancy.”
b.	“Now there. You can try to conceive on your next cycle.”
c.	“I’m here if you need to talk.”
d.	“You are young and strong. I know you can have a healthy pregnancy.”

 

 

ANS:  C

An effective technique when communicating with a woman experiencing pregnancy loss is to say, “I’m here if you need to talk.” The nurse listens and acknowledges the woman’s grief.

 

DIF:    Cognitive Level: Application           REF:   Page 85          OBJ:   4

TOP:   Dilation and Evacuation (D&E)       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

4. A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding accompanied by abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman understands the explanation of an ectopic pregnancy?

a.	“The chorionic villi develop vesicles within the uterus.”
b.	“The placenta develops in the lower part of the uterus.”
c.	“The fetus dies in the uterus during the first half of the pregnancy.”
d.	“The embryo is implanted in the fallopian tube.”

 

 

ANS:  D

Ectopic pregnancy occurs when the fertilized ovum is implanted outside of the uterine cavity.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 86          OBJ:   4

TOP:   Ectopic Pregnancy                           KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

5. An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical os. What does the nurse understand best describes this condition?

a.	Low-lying placenta
b.	Marginal placenta previa
c.	Partial placenta previa
d.	Total placenta previa

 

 

ANS:  D

A total placenta previa describes a condition in which the placenta completely covers the cervical opening.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 88-89     OBJ:   4

TOP:   Placenta Previa                               KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

6. What symptom presented by a pregnant women is indicative of abruptio placentae?

a.	Painless vaginal bleeding
b.	Uterine irritability with contractions
c.	Vaginal bleeding and back pain
d.	Premature rupture of membranes

 

 

ANS:  C

Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 89          OBJ:   4

TOP:   Abruptio Placenta                            KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

7. What situation would concern the nurse about the presence of Rh incompatibility?

a.	Rh-negative mother, Rh-positive fetus
b.	Rh-positive mother, Rh-negative fetus
c.	Rh-negative mother, Rh-negative fetus
d.	Rh-positive mother, Rh-positive fetus

 

 

ANS:  A

Rh incompatibility can occur only if the mother is Rh negative and the fetus is Rh positive.

 

DIF:    Cognitive Level: Analysis                REF:   Page 95          OBJ:   4

TOP:   Rh Incompatibility                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

8. A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh antibodies from forming?

a.	Rh immune globulin during labor
b.	Intrauterine transfusions with O-negative blood
c.	Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant
d.	Rh immune globulin now and again in the last trimester

 

 

ANS:  C

An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after the birth of an Rh-positive infant or abortion.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 95          OBJ:   4

TOP:   Rh Incompatibility                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

9. A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest?

a.	Toxoplasmosis
b.	Abruptio placentae
c.	Hydatidiform mole
d.	Diabetes mellitus

 

 

ANS:  D

Large (macrosomic) infants over 9 pounds are linked to gestational diabetes.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 96          OBJ:   5

TOP:   Diabetes Mellitus                            KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

10. A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism in what way?

a.	Placental hormones increase the resistance of cells to insulin.
b.	Insulin cells cannot meet the body’s demands as the woman’s weight increases.
c.	There is a decreased production of insulin during pregnancy.
d.	The speed of insulin breakdown is decreased during pregnancy.

 

 

ANS:  A

Hormones and enzymes produced by the placenta increase the resistance of cells to insulin.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 96          OBJ:   5

TOP:   Diabetes Mellitus                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

11. Why does the woman taking oral hypoglycemic agents to control diabetes mellitus  need to take insulin during pregnancy?

a.	Insulin can cross the placental barrier to the fetus.
b.	Insulin does not cross the placental barrier to the fetus.
c.	Oral agents do not cross the placenta.
d.	Oral agents are not sufficient to meet maternal insulin needs.

 

 

ANS:  B

Oral hypoglycemic agents are not used during pregnancy because they can cross the placenta, possibly resulting in fetal birth defects or hypoglycemia.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 97 | Page 100

OBJ:   5                    TOP:   Diabetes Mellitus

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

12. A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that her infant will also contract hepatitis B. What will the nurse explain to this woman?

a.	The infant will be given a single dose of hepatitis immune globulin after birth.
b.	The infant will be able to use the antibodies from the immunizations given to the patient before delivery.
c.	The infant will not have hepatitis B because the virus does not pass through the placental barrier.
d.	The infant will be immune to hepatitis B because of the mother’s infection.

 

 

ANS:  A

The infant will be given immune globulin immediately after birth for temporary immunity followed by hepatitis B vaccine. Immunization is not recommended for women who are pregnant.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 104-105

OBJ:   5                    TOP:   Hepatitis B     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

13. What will the nurse begin with when asking a patient about drug use during a prenatal history?

a.	“Do you smoke, drink alcohol, or use drugs?”
b.	“Do you ever use prescription or street drugs?”
c.	“What over-the-counter and prescription drugs have you taken in the past 3 months?”
d.	“We need to know if you take drugs so we can help your baby.”

 

 

ANS:  C

Screening for drug use should begin in a nonthreatening way by asking about prescription and OTC medications and how the information can help provide safe and appropriate prenatal care.

 

DIF:    Cognitive Level: Application           REF:   Page 108 | Page 110

OBJ:   6                    TOP:   Interviewing Relative to Drug Use

KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

14. The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication?

a.	Abdominal enlargement
b.	Facial swelling
c.	Sudden weight gain
d.	Swelling of the feet and ankles

 

 

ANS:  C

Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs, and hands follow weight gain.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 91          OBJ:   4

TOP:   Hypertension                                  KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

15. A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report immediately?

a.	Diarrhea
b.	Urticaria
c.	Blurred vision
d.	Backache

 

 

ANS:  C

Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for effective intervention to prevent preeclampsia and convulsion.

 

DIF:    Cognitive Level: Application           REF:   Page 91          OBJ:   4

TOP:   Hypertension                                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

16. A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home health nurse make the first priority?

a.	Activity restriction
b.	Balanced nutrition
c.	Increased fluid intake to ensure adequate hydration
d.	Instruction about the effect of diuretics

 

 

ANS:  A

Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and enhancing fetal oxygenation.

 

DIF:    Cognitive Level: Application           REF:   Page 92          OBJ:   4

TOP:   Hypertension                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

17. The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient?

a.	To prevent convulsions
b.	To promote diaphoresis
c.	To increase reflex irritability
d.	To act as a saline cathartic

 

 

ANS:  A

Magnesium sulfate is a central nervous system depressant given to prevent seizures.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 92-93     OBJ:   4

TOP:   Magnesium Sulfate                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

18. The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the most appropriate nursing intervention?

a.	Count respirations and report a rate of less than 12 breaths/min.
b.	Count respirations and report a rate of more than 20 breaths/min.
c.	Check blood pressure and report a rate of less than 100/60 mm Hg.
d.	Monitor urinary output and report a rate of less than 100 mL/hr.

 

 

ANS:  A

Excessive magnesium sulfate may cause respiratory depression.

 

DIF:    Cognitive Level: Application           REF:   Page 93 | Page 95

OBJ:   4                    TOP:   Magnesium Sulfate

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

19. What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient?

a.	Ergonovine maleate (Ergotrate)
b.	Oxytocin
c.	Calcium gluconate
d.	Hydralazine (Apresoline)

 

 

ANS:  C

Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a woman receives magnesium sulfate.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 93          OBJ:   4

TOP:   Calcium Gluconate                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

20. A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, “Will I be able to deliver vaginally?” What explanation by the nurse is the most appropriate?

a.	“Yes, you can deliver vaginally until 36 weeks.”
b.	“A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done.”
c.	“A cesarean section is performed when the mother has a total placenta previa.”
d.	“There is no reason why you cannot have a vaginal delivery.”

 

 

ANS:  C

A cesarean delivery is done for a partial or total placenta previa.

 

DIF:    Cognitive Level: Application           REF:   Page 90          OBJ:   4

TOP:   Placenta Previa                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

21. The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus. What can result from maternal rubella during pregnancy?

a.	Facial abnormalities
b.	Mental retardation
c.	Liver failure
d.	Limb deformities

 

 

ANS:  B

Rubella can have devastating effects on the developing fetus. Some effects of rubella on the embryo or fetus include microcephaly, mental retardation, cardiac defects, cataracts, and deafness.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 104        OBJ:   5

TOP:   Rubella          KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

22. What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis?

a.	Frequency and urgency of urination
b.	Nausea and weight loss
c.	Burning sensation when voiding
d.	Tenderness in the flank area

 

 

ANS:  D

Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills, flank pain or tenderness, nausea, and vomiting.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 107        OBJ:   5

TOP:   Pyelonephritis                                 KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

23. The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient?

a.	Flat on her back with knees flexed to help prevent hemorrhage
b.	On her side to prevent supine hypotension
c.	In the semi-Fowler’s position to prevent supine hypotension
d.	In the knee-chest position to reduce pressure on the placenta

 

 

ANS:  B

The prenatal patient with placenta previa is best placed on her side with a pillow for support. This position not only reduces stress on the placenta but also reduces the possibility of supine hypotension.

 

DIF:    Cognitive Level: Application           REF:   Page 89          OBJ:   4

TOP:   Placenta Previa                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

24. The young prenatal patient with gestational diabetes mellitus (GDM) says, “I am frightened that I will have to deal with insulin injections for the rest of my life.” What is the best response by the nurse?

a.	“After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections.”
b.	“Have you considered an insulin pump?”
c.	“After a while those insulin injections won’t seem so bad.”
d.	“It will most likely resolve 6 weeks or so after the baby is born.”

 

 

ANS:  D

GDM usually resolves by 6 weeks after delivery.

 

DIF:    Cognitive Level: Application           REF:   Page 97          OBJ:   4

TOP:   GDM              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

25. The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks’ gestation. What intervention will the nurse implement before this diagnostic test?

a.	Instruct the patient to take nothing by mouth after midnight the night before the test.
b.	Initiate an IV.
c.	Encourage the patient to drink 1 to 2 quarts of water before the test.
d.	Instruct the patient to remove all jewelry.

 

 

ANS:  C

Ultrasound uses high-frequency sound waves to visualize structures within the body; the examination may use a transvaginal probe or an abdominal transducer; abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination).

 

DIF:    Cognitive Level: Application           REF:   Page 80, Table 5-1

OBJ:   2                    TOP:   Diagnostic Tests

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prenatal Care

 

MULTIPLE RESPONSE

 

26. The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will the nurse assess for in the newborn? (Select all that apply.)

a.	Meconium ileus
b.	Diarrhea
c.	Hypoglycemia
d.	Muscle tremors
e.	Urine retention

 

 

ANS:  C

The fetus responds to the hyperglycemia from the mother’s blood and produces increased insulin. This insulin may cause hypoglycemia in the infant after it is no longer exposed to the mother’s blood.

 

DIF:    Cognitive Level: Application           REF:   Page 97, Box 5-4

OBJ:   5                    TOP:   Hypoglycemia in Macrosomic Infant

KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

27. The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.)

a.	Toxoplasmosis
b.	Toxemia
c.	Cytomegalovirus
d.	Rubella
e.	Herpes simplex

 

 

ANS:  A, C, D, E

The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 103        OBJ:   6

TOP:   TORCH Infections                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

28. The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might result in which problems? (Select all that apply.)

a.	Disruption of family roles
b.	Financial pressures
c.	Excessive attachment to infant
d.	Frustration with activity restriction
e.	Alteration in child care practices

 

 

ANS:  A, B, D, E

High-risk pregnancies may produce problems such as disruption of family roles, financial pressures, delayed attachment to the infant, alteration in child care practices, and frustration with activity restriction.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 112        OBJ:   8

TOP:   Impact of High-Risk Pregnancies     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

29. A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.)

a.	Privacy
b.	An opportunity to hold the infant
c.	Materials about support groups
d.	A memento (footprint or lock of hair)
e.	A warm beverage

 

 

ANS:  A, B, C, D

The patient should be offered privacy, an opportunity to hold the infant, support group information, and a memento.  A warm beverage is not a priority at this time.

 

DIF:    Cognitive Level: Application           REF:   Page 112        OBJ:   8

TOP:   Stillborn Infant                                KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

30. What would the nurse include in a teaching plan for the pregnant patient who has iron deficiency anemia and has been placed on iron supplements? (Select all that apply.)

a.	Citrus fruits enhance absorption of iron.
b.	Bran products support iron deficiency.
c.	Milk will disguise the taste of the iron.
d.	The iron therapy will continue for about 3 months.
e.	Tea should be avoided while taking iron.

 

 

ANS:  A, D, E

Calcium, bran, and milk interfere with the absorption of iron. Vitamin C helps with the absorption of iron, the therapy usually lasts 3 months, and the tannic acid in tea does interfere with the absorption of iron.

 

DIF:    Cognitive Level: Application           REF:   Page 102        OBJ:   5

TOP:   Iron Deficiency Anemia                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

31. The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection for what reasons? (Select all that apply.)

a.	Vaginal organisms can invade the placenta.
b.	The undernourished placenta becomes necrotic.
c.	The amniotic fluid can become infected.
d.	The placenta is an excellent growth medium.
e.	The misplaced placenta weakens the uterine wall.

 

 

ANS:  A, D

Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the nutrient-rich environment of the placenta. The weak musculature of the lower segment of the uterus will cause postpartum hemorrhage rather than infection.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 88-89     OBJ:   3

TOP:   Infection with Placenta Previa          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

32. The nurse is obtaining history and physical information on a new patient attending her first prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.)

a.	Gestational diabetes
b.	RH Incompatibility
c.	Hypertension
d.	Pre-eclampsia
e.	Infection

 

 

ANS:  A, C, D

The obese woman who is pregnant has a high risk for developing complications during pregnancy such as gestational diabetes, hypertension, cardiac problems, pre-eclampsia, and respiratory problems.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 103        OBJ:   4

TOP:   Obesity          KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

 

33. A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.)

a.	Tell the husband that authorities will be notified immediately.
b.	Provide privacy for the assessment.
c.	Determine if children are being hurt.
d.	Communicate in a non-judgmental way.
e.	Determine factors that increase the risk of injury.

 

 

ANS:  B, C, D, E

The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The nurse also determines whether children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she intends to leave.

 

DIF:    Cognitive Level: Application           REF:   Page 110-111

OBJ:   7                    TOP:   Battering        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Injury Prevention

 

COMPLETION

 

34. The nurse cautions that the consumption of as few as ________ alcoholic drink(s) during pregnancy can lead to the loss of fetal brain cells.

 

ANS:

two

 

Studies have shown that even as few as two alcoholic drinks consumed during pregnancy can cause loss of fetal brain cells. A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of liquor.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 110, Nursing Tip

OBJ:   5                    TOP:   Fetal Alcohol Syndrome

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

35. The nurse explains that ___________ is a procedure in which an incompetent cervix is sutured closed to prevent its opening when the fetus presses against it.

 

ANS:

cerclage

 

Cerclage is the procedure that sutures the cervix closed to prevent its opening when the fetus presses against it.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 83          OBJ:   1

TOP:   Cerclage         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

36. ________________________ ________________________ is the leading cause of perinatal infections that have a high mortality rate.

 

ANS:

Group B streptococcus (GBS)

 

Group B streptococcus (GBS) is a leading cause of perinatal infections that have a high neonatal mortality rate. The organism can be found in the woman’s rectum, vagina, cervix, throat, or skin.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 106        OBJ:   3 | 4

TOP:   Perinatal Infections                          KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Health Promotion and Maintenance: Antepartum and Newborn Care

 

37. A(n) _________________________________ consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amniotic fluid.

 

ANS:

biophysical profile

 

A biophysical profile consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amniotic fluid.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 81, Table 5-1

OBJ:   2                    TOP:   Diagnostic tests

KEY:  Nursing Process Step: Data Collection

MSC:  NCLEX: Heath Promotion and Maintenance: Prenatal Care