A nurse is explaining to the nursing students working on the antepartum unit how to assess for edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area?

+3

Which maternal condition always necessitates delivery by cesarean birth?

Total placenta previa

Spontaneous termination of a pregnancy is considered to be an abortion if

the pregnancy is less than 20 weeks.

An abortion when the fetus dies but is retained in the uterus is called

missed.

A placenta previa when the placental edge just reaches the internal os is called

marginal.

Which finding would indicate concealed hemorrhage in abruptio placentae?

Hard boardlike abdomen

The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to

assess fetal heart rate and maternal vital signs.

A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate

worsening disease and impending convulsion.

Rh incompatibility can occur if the patient is Rh-negative and the

fetus is Rh-positive.

In which situation would a dilation and curettage (D&C) be indicated?

Incomplete abortion at 10 weeks

Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?

Recurrent pelvic infections

Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?

Fundal height measurement of 18 cm

Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?

Determining cervical dilation and effacement

A laboratory finding indicative of DIC is one that shows

decreased fibrinogen.

Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?

Normal deep tendon reflexes

A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication, which action should the nurse take?

Administer calcium gluconate.

A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following?

Hemorrhage is the primary concern.

A patient who was pregnant had a spontaneous abortion at approximately 4 weeks’ gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of “crampy” abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm), and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?

Uterine infection

A patient with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the patient is questioned, she relates that there is history of heart disease in her family; but, that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the patient is discharged. The patient returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension is the patient is exhibiting?

Undiagnosed chronic hypertension

A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?

Platelet count of 50,000/mcL

As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that

immediate birth is required.

A patient who had premature rupture of the membranes (PROM) earlier in the pregnancy at28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The laborand birth nurse performs the following assessments. The vaginal exam is deferred until the physician is in attendance. the patient is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The patient is then transferred to the antepartum unit for continued observation. Several hours later, the patient complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The patient is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?

Hidden placental abruption

What is the priority nursing intervention for the patient who has had an incomplete abortion?

Insertion of IV line for fluid replacement

Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?

Bleeding at IV insertion site

Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?

Pain level 0 on a scale of 0 to 10

A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.

900

Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?

Administration of methotrexate

Which finding in the exam of a patient with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion?

Clear fluid from vagina

What should the nurse recognize as evidence that the patient is recovering from preeclampsia?

Urine output >100 mL/hour

Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the

indirect Coombs test of the mother.

For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to

6:30 AM on January 13.

The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?

Male fetus, African-American, previous cesarean birth

A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient’s magnesium level is 7.6 mg/dL. What is the nurse’s priority action?

Assess the patient’s respiratory rate.

Which factor is most important in diminishing maternal, fetal, and neonatal complications in a pregnant patient with diabetes?

Degree of glycemic control before and during the pregnancy

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?

Hypoglycemia

Which factor is known to increase the risk of gestational diabetes mellitus?

Previous birth of large infant

Which disease process improves during pregnancy?

Rheumatoid arthritis

Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is

varied depending on the stage of gestation.

Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?

Mitral valve prolapse

Which instructions should the nurse include when teaching a pregnant patient with Class II heart disease?

Instruct her to avoid strenuous activity.

Anti-infective prophylaxis is indicated for a pregnant patient with a history of mitral valve stenosis related to rheumatic heart disease because the patient is at risk of developing

bacterial endocarditis.

A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?

She must make arrangements to stay somewhere other than her home until the children are no longer contagious.

A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate?

Plan for retesting during the third trimester.

A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?

Even though my test is positive, my baby might not be affected.

Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?

Rubella

Which postpartum patient requires further assessment?

G1 P1 with Class II heart disease who complains of frequent coughing

The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement?

I will have blood drawn at 1 hour after I drink the glucose solution.”

The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?

Ask the patient when she last had anything to eat or drink.

The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)

Altered sensorium

Respiratory rate of less than 12 breaths per minute

Absence of deep tendon reflexes

The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)

Birth defects

Venous thromboembolism

Postpartum anemia

A pregnant patient who abuses cocaine admits to exchanging sex for her drug habit. This behavior puts her at a greater risk for

sexually transmitted diseases.

Which factor is a major barrier to health care for adolescent mothers?

Seeing a different nurse and/or health care provider at every visit.

In planning sex education classes for the middle school age group, more emphasis should be placed on

how to set limits for sexual behavior.

Which action should the nurse take when counseling a teenaged patient who has decided to relinquish her baby for adoption?

Affirm her decision while acknowledging her maturity in making it

A patient who is older than 35 years may have difficulty achieving pregnancy because

the ovaries may be affected by the normal aging process.

Which health concern is most likely to be an issue for the older mother?

Having enough rest and sleep

Which is the most dangerous effect on the fetus of a patient who smokes cigarettes while pregnant?

Intrauterine growth restriction

A patient at 24 weeks of gestation reports that she has a glass of wine with dinner every evening. Which rationale should the nurse provide this patient regarding the necessity to eliminate alcohol intake?

The fetus is placed at risk for altered brain growth.

Which of the following is an example of healthy grieving?

While holding the baby, the mother says to her husband, “He has your eyes and nose.”

A patient has delivered twins. The first twin was stillborn, and the second is in the intensive care nursery, recovering quickly from respiratory distress. The patient is crying softly and says, “I wish my baby could have lived.” What is the most therapeutic response?

“I am so sorry about your loss. Would you like to talk about it?

Which action is the most appropriate nursing measure when a baby has an unexpected defect at birth?

Explain the defect and show the baby to the parents as soon as possible.

Which environment can assist a pregnant teen to achieve the task of establishing a stable identity?

School-based mothers’ program

Which complication of adolescent pregnancy should the nurse plan to monitor?

Anemia

The nurse is seeing a 17-year-old female in the clinic for complaints of acne. The nurse plans on taking advantage of this teachable moment with the teen. Which topics will the nurse include in the teen’s teaching plan?

Sexual activity, contraception, and screening for violence

A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that she has a daily heroin habit. The nurse discusses treatment options for the patient. Which patient statement requires follow-up?

My baby will not have to go through withdrawal when I take methadone.”

Which data in the patient’s history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?

Previous depressive episode

Which nursing diagnoses may apply to the childbearing family with special needs? (Select all that apply.)

Risk for spiritual distress

Risk for injury

Situational low self-esteem

Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)

Continuing to deny the pregnancy

Uncertainty about where to go for care

Lack of realization that they are pregnant

Wanting to hide the pregnancy as long as possible

Which characteristics of fetal alcohol syndrome (FAS) should the nurse expect to assess in affected neonates? (Select all that apply.)

Epicanthal folds

Short palpebral fissures

Flat midface, with a low nasal bridge

Which congenital defects in a newborn are associated with long-term parenting problems? (Select all that apply.)

Cleft lip and palate

Ambiguous genitalia