Chapter 18 Pregnancy at Risk: Gestational Onset My Nursing Test Banks

Olds Maternal-Newborn Nursing and Womens Health, 10e (Davidson)

Chapter 18 Pregnancy at Risk: Gestational Onset

1) The nurse is caring for a client who was just admitted to rule out ectopic pregnancy. Which orders are the most important for the nurse to perform?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Assess the clients temperature.

2. Document the time of the clients last meal.

3. Obtain urine for urinalysis and culture.

4. Report complaints of dizziness or weakness.

5. Have the lab draw blood for B-hCG level every 48 hours.

Answer: 4, 5

Explanation: 4. Reporting complaints of dizziness and weakness is important, as it can indicate hypovolemia from internal bleeding.

5. Having the lab draw blood for B-hCG levels every 48 hours is important, as the level rises much more slowly in ectopic pregnancy than in normal pregnancy.

Page Ref: 376, 377

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

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2) The nurse educator is presenting a class on the different kinds of miscarriages. Miscarriages, or spontaneous abortions, are classified clinically into which of the following different categories?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Threatened abortion

2. Incomplete abortion

3. Complete abortion

4. Missed abortion

5. Acute abortion

Answer: 1, 2, 3, 4

Explanation: 1. Unexplained cramping, bleeding, or backache indicates the fetus might be in jeopardy. This is a threatened abortion.

2. In an incomplete abortion, parts of the products of conception are retained, most often the placenta.

3. In a complete abortion, all the products of conception are expelled. The uterus is contracted and the cervical os may be closed.

4. In a missed abortion, the fetus dies in utero but is not expelled.

Page Ref: 374

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Management of Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

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3) The nurse is presenting a class on the pathophysiology of the different abortions. Some of the causes are which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Chromosomal abnormalities

2. Insufficient or excessive hormonal levels

3. Sexual intercourse in the first trimester

4. Infections in the first trimester

5. Cervical insufficiency

Answer: 1, 2, 4, 5

Explanation: 1. Chromosomal defects are generally seen as spontaneous abortions during weeks 4 to 8.

2. Insufficient or excessive hormonal levels usually will result in spontaneous abortion by 10 weeks gestation.

4. Infectious and environmental factors may also be seen in first trimester pregnancy loss.

5. In late spontaneous abortion, the cause is usually a maternal factor, for example, cervical insufficiency or maternal disease, and fetal death may not precede the onset of abortion.

Page Ref: 373

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Safety and Infection Control

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan and in all health care settings. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

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4) A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what?

1. Sodium

2. Carbohydrates

3. Protein

4. Fruits

Answer: 3

Explanation: 3. The client who experiences preeclampsia is losing protein.

Page Ref: 386

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

5) The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician?

1. Excretion of less than 300 mg of protein in a 24-hour period

2. Platelet count of less than 100,000/mm3

3. Urine output of 50 mL per hour

4. 12 respirations

Answer: 2

Explanation: 2. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 100,000/mm3).

Page Ref: 384

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

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6) A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, Is my baby going to be okay? In addition to acknowledging the clients fear, what should the nurse also say?

1. Your baby will be fine. Well start IV, and get this stopped in no time at all.

2. Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now.

3. You are going to miscarry. But you should be relieved because most miscarriages are the result of abnormalities in the fetus.

4. I really cant say. However, when your physician comes, Ill ask her to talk to you about it.

Answer: 2

Explanation: 2. If bleeding persists and abortion is imminent or incomplete, the woman may be hospitalized, IV therapy or blood transfusions may be started to replace fluid, and dilation and curettage (D&C) or suction evacuation is performed to remove the remainder of the products of conception.

Page Ref: 375

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas of the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

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7) The nurse is supervising care in the emergency department. Which situation most requires an intervention?

1. Moderate vaginal bleeding at 36 weeks gestation; client has an IV of lactated Ringers solution running at 125 mL/hour

2. Spotting of pinkish-brown discharge at 6 weeks gestation and abdominal cramping; ultrasound scheduled in 1 hour

3. Bright red bleeding with clots at 32 weeks gestation; pulse = 110, blood pressure 90/50, respirations = 20

4. Dark red bleeding at 30 weeks gestation with normal vital signs; client reports an absence of fetal movement

Answer: 3

Explanation: 3. Bleeding in the third trimester is usually a placenta previa or placental abruption. Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness. Monitor vital signs, particularly blood pressure and pulse, for evidence of developing shock.

Page Ref: 373

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors or actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

MNL LO: 2.7.3 Contrast the bleeding disorders of late pregnancy and their implications for nursing care.

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8) A client who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain. Laboratory tests reveal a beta-hCG at a lower-than-expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The client is crying and asks what is happening. The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include?

1. Youre feeling dizzy because the pregnancy is compressing your vena cava.

2. The pain is due to the baby putting pressure on nerves internally.

3. The baby is in the fallopian tube; the tube has ruptured and is causing bleeding.

4. This is a minor problem. The doctor will be right back to explain it to you.

Answer: 3

Explanation: 3. The woman who experiences one-sided lower abdominal pain or diffused lower abdominal pain, vasomotor disturbances such as fainting or dizziness, and referred right shoulder pain from blood irritating the subdiaphragmatic phrenic nerve is experiencing an ectopic pregnancy.

Page Ref: 376

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

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9) A client at 18 weeks gestation has been diagnosed with a hydatidiform mole. In addition to vaginal bleeding, which signs or symptoms would the nurse expect to see?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Hyperemesis gravidarum

2. Diarrhea and hyperthermia

3. Uterine enlargement greater than expected

4. Polydipsia

5. Vaginal bleeding

Answer: 1, 3, 5

Explanation: 1. This is often seen in clients with hydatidiform mole.

3. This is a classic sign of hydatidiform mole.

5. This is a classic symptom of hydatidiform mole.

Page Ref: 378

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

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10) A woman at 7 weeks gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority?

1. Fluid Volume: Deficient

2. Cardiac Output, Decreased

3. Injury, Risk for

4. Nutrition, Imbalanced: Less than Body Requirements

Answer: 1

Explanation: 1. The newly admitted client with hyperemesis gravidarum has been experiencing excessive vomiting, and is in a fluid volume-deficit state.

Page Ref: 380

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management, across the health-illness continuum, across lifespan and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3 Discuss the medical therapy and nursing care of a woman with hyperemesis gravidarum.

MNL LO: 2.7.4 Discuss the effects of hyperemesis gravidarum on pregnancy.

11) The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?

1. Weigh the client.

2. Give 1 liter of lactated Ringers solution IV.

3. Administer 30 mL Maalox (magnesium hydroxide) orally.

4. Encourage clear liquids orally.

Answer: 2

Explanation: 2. The vital signs indicate hypovolemia from dehydration, which leads to hypotension and increased pulse rate. Giving this client a liter of lactated Ringers solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.

Page Ref: 380

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce harm to self or others. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Teamwork: Function competently within ones own scope of practice as leader or member of the health care team, and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Discuss the medical therapy and nursing care of a woman with hyperemesis gravidarum.

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MNL LO: 2.7.4 Discuss the effects of hyperemesis gravidarum on pregnancy.

12) A pregnant client has been admitted with a diagnosis of hyperemesis. Which orders written by the primary healthcare provider are the highest priorities for the nurse to implement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Obtain complete blood count.

2. Start intravenous fluid with multivitamins.

3. Check admission weight.

4. Obtain urine for urinalysis.

5. Give a medication to stop the nausea and vomiting.

Answer: 2, 5

Explanation: 2. Starting intravenous fluid with multivitamins is a priority if the client has been vomiting.

5. Giving a medication to stop the nausea and vomiting is a priority.

Page Ref: 380

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Teamwork: Function competently within ones own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Discuss the medical therapy and nursing care of a woman with hyperemesis gravidarum.

MNL LO: 2.7.4 Discuss the effects of hyperemesis gravidarum on pregnancy.

13) A primary herpes simplex infection in the first trimester can increase the risk of which of the following?

1. Spontaneous abortion

2. Preterm labor

3. Intrauterine growth restriction

4. Neonatal infection

Answer: 1

Explanation: 1. A primary herpes simplex infection can increase the risk of spontaneous abortion when infection occurs in the first trimester.

Page Ref: 396

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Teamwork: Function competently within ones own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning

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Learning Outcome: 5 Contrast the effects of various infections on the pregnant woman and her unborn child.

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14) A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity?

1. Patellar reflexes weak or absent

2. Increased appetite

3. Respiratory rate of 16

4. Fetal heart rate of 120

Answer: 1

Explanation: 1. Early signs of magnesium sulfate toxicity are related to a decrease in deep tendon reflexes.

Page Ref: 389

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

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15) Doppler flow studies (umbilical velocimetry) help to assess which of the following?

1. Placental function and sufficiency

2. Fetal heart rate

3. Fetal growth and fluid levels

4. Maturity of the fetal lungs

Answer: 1

Explanation: 1. Doppler flow studies (umbilical velocimetry) help to assess placental function and sufficiency. Uteroplacental insufficiency is a risk for a woman with preeclampsia. If fetal growth restriction is present, Doppler velocimetry of the umbilical artery is useful for fetal surveillance.

Page Ref: 390

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Context and environment: Read and interpret data; apply health promotion/disease prevention strategies. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

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16) When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the womans condition closely. At that time, which of the following should be assessed?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Fetal heart rate

2. Blood pressure

3. Temperature

4. Urine color

5. Pulse and respirations

Answer: 1, 2, 3, 5

Explanation: 1. Determine the fetal heart rate along with blood pressure, or monitor continuously with the electronic fetal monitor if the situation indicates.

2. Determine blood pressure every 1 to 4 hours, or more frequently if indicated by medication or other changes in the womans status.

3. Determine temperature every 4 hours, or every 2 hours if elevated or if premature rupture of the membranes (PROM) has occurred.

5. Determine pulse rate and respirations along with blood pressure.

Page Ref: 388

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

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17) The community nurse is working with a client at 32 weeks gestation who has been diagnosed with preeclampsia. Which statement by the client would indicate that additional information is needed?

1. I should call the doctor if I develop a headache or blurred vision.

2. Lying on my left side as much as possible is good for the baby.

3. My urine could become darker and smaller in amount each day.

4. Pain in the top of my abdomen is a sign my condition is worsening.

Answer: 3

Explanation: 3. Oliguria is a complication of preeclampsia. Specific gravity of urine readings over 1.040 correlate with oliguria and proteinuria and should be reported to the physician.

Page Ref: 388

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

18) Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of which condition?

1. Intrauterine growth restriction

2. Oliguria

3. Proteinuria

4. Hypertension

Answer: 1

Explanation: 1. Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of intrauterine growth restriction. The cause is related specifically to maternal vasospasm and hypovolemia, which result in fetal hypoxia and malnutrition.

Page Ref: 384

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing

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care.

19) A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurses best response?

1. This medication will halt the labor process until the baby is more mature.

2. This medication will relax the smooth muscles in the infants lungs so the baby can breathe.

3. This medication is effective in stimulating lung development in the preterm infant.

4. This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor.

Answer: 3

Explanation: 3. Betamethasone or dexamethasone is often administered to the woman whose fetus has an immature lung profile to promote fetal lung maturation.

Page Ref: 386

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

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20) A client is being admitted to the labor area with the diagnosis of eclampsia. Which actions by the nurse are appropriate at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Tape a tongue blade to the head of the bed.

2. Pad the side rails.

3. Have the woman sit up.

4. Provide the client with grief counseling.

5. The airway should be maintained and oxygen administered.

Answer: 2, 5

Explanation: 2. Side rails should be up and padded.

5. Suctioning may be necessary to keep the airway clear.

Page Ref: 387

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

MNL LO: 2.7.1 Contrast the various hypertensive disorders in pregnancy and appropriate nursing care.

21) A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant client. When should the first dose of RhoGAM be administered?

1. After the birth of the infant

2. 1 month postpartum

3. During labor

4. At 28 weeks gestation

Answer: 4

Explanation: 4. When the woman is Rh negative and not sensitized and the father is Rh positive or unknown, Rh immune globulin is given prophylactically at 28 weeks gestation.

Page Ref: 405

Cognitive Level: Remembering

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Function competently within ones own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning

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Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the newborn secondary to Rh incompatibility.

22) Whether sensitization is the result of a blood transfusion or maternal-fetal hemorrhage for any reason, what test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed?

1. Indirect Coombs test

2. Nonstress test

3. Kleihauer-Betke or rosette test

4. Direct Coombs test

Answer: 3

Explanation: 3. A Kleihauer-Betke or rosette test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed.

Page Ref: 405

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the newborn secondary to Rh incompatibility.

23) The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?

1. I need to get RhoGAM so I dont have problems with my next pregnancy.

2. Because my baby is Rh-positive, I dont need RhoGAM.

3. If my baby had the same blood type I do, it might cause complications.

4. Before my next pregnancy, I will need to have a RhoGAM shot.

Answer: 1

Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization.

Page Ref: 405, 407

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively;

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listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the newborn secondary to Rh incompatibility.

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24) Which maternal-child client should the nurse see first?

1. Blood type O, Rh-negative

2. Indirect Coombs test negative

3. Direct Coombs test positive

4. Blood type B, Rh-positive

Answer: 3

Explanation: 3. Direct Coombs test is done on the infants blood to detect antibody-coated Rh-positive RBCs. If the mothers indirect Coombs test is positive and her Rh-positive infant has a positive direct Coombs test, Rh immune globulin is not given; in this case, the infant is carefully monitored for hemolytic disease.

Page Ref: 407

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Teamwork: Function competently within ones own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the newborn secondary to Rh incompatibility.

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25) A client is concerned because she has been told her blood type and her babys are incompatible. What is the nurses best response?

1. This is called ABO incompatibility. It is somewhat common but rarely causes significant hemolysis.

2. This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy.

3. This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby.

4. This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring.

Answer: 1

Explanation: 1. When blood types, not Rh, are incompatible, it is called ABO incompatibility. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal RBCs.

Page Ref: 408

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, treatment, and implications for the fetus/newborn.

26) If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent what?

1. The potential for hemorrhage

2. Hyperhomocysteinemia

3. Antibody formation

4. Tubal pregnancy

Answer: 3

Explanation: 3. If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent antibody formation.

Page Ref: 379

Cognitive Level: Remembering

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, treatment, and implications for the fetus/newborn.

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27) The client presents to the clinic for an initial prenatal examination. She asks the nurse whether there might be a problem for her baby because she has type B Rh-positive blood and her husband has type O Rh-negative blood, or because her sisters baby had ABO incompatibility. What is the nurses best answer?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Your baby would be at risk for Rh problems if your husband were Rh-negative.

2. Rh problems only occur when the mother is Rh-negative and the father is not.

3. ABO incompatibility occurs only after the baby is born.

4. We dont know for sure, but we can test for ABO incompatibility.

5. Your husbands being type B puts you at risk for ABO incompatibility.

Answer: 2, 3

Explanation: 2. Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive.

3. ABO incompatibility is limited to type O mothers with a type A or B fetus and occurs after the baby is born.

Page Ref: 408

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, treatment, and implications for the fetus/newborn.

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28) A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the client understands that what is essential?

1. That she not become pregnant until after the follow-up program is completed

2. That she receive RhoGAM with her next pregnancy and birth

3. That she has her blood pressure checked weekly for the next 30 days

4. That she seek genetic counseling with her partner before the next pregnancy

Answer: 1

Explanation: 1. Because of the risk of choriocarcinoma, the woman treated for hydatidiform mole should receive extensive follow-up therapy. Follow-up care includes a baseline chest X-ray to detect lung metastasis and a physical examination including a pelvic examination. The woman should avoid pregnancy during this time because the elevated hCG levels associated with pregnancy would cause confusion as to whether cancer had developed.

Page Ref: 379

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy.

MNL LO: 2.7.2 Describe the causes of bleeding in early pregnancy and their implications for nursing care.

29) A client at 10 weeks gestation has developed cholecystitis. If surgery is required, what is the safest time during pregnancy?

1. Immediately, before the fetus gets any bigger

2. Early in the second trimester

3. As close to term as possible

4. The risks are too high to do it anytime in pregnancy

Answer: 2

Explanation: 2. The early second trimester is the best time to operate because there is less risk of spontaneous abortion or early labor, and the uterus is not so large as to impinge on the abdominal field.

Page Ref: 400

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. Demonstrate effective strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6 Summarize the risks and implications of surgical procedures performed during pregnancy.

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30) The nurse is presenting a class to newly pregnant families. What form of trauma will the nurse describe as the leading cause of fetal and maternal death?

1. Falls

2. Domestic violence

3. Gun accidents

4. Motor vehicle accidents

Answer: 4

Explanation: 4. Trauma from motor vehicle accidents is the leading cause of fetal and maternal death.

Page Ref: 401

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Relate the impact of major trauma during pregnancy to the nursing care of the woman and her fetus.

31) During a prenatal exam, a client describes several psychosomatic symptoms and has several vague complaints. What could these behaviors indicate?

1. Abuse

2. Mental illness

3. Depression

4. Nothing, they are normal

Answer: 1

Explanation: 1. Chronic psychosomatic symptoms and vague complaints can be indicators of abuse.

Page Ref: 403

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Abuse/Neglect

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8 Discuss the needs and care of the pregnant woman who suffers abuse.

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32) The nurse is caring for a client at 35 weeks gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern?

1. Blood pressure 110/68, pulse 90.

2. Entrance wound present below the umbilicus.

3. Client is positioned in a left lateral tilt.

4. Clear fluid is leaking from the vagina.

Answer: 2

Explanation: 2. Penetrating trauma includes gunshot wounds and stab wounds. The mother generally fares better than the fetus if the penetrating trauma involves the abdomen as the enlarged uterus is likely to protect the mothers bowel from injury.

Page Ref: 402

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Relate the impact of major trauma during pregnancy to the nursing care of the woman and her fetus.

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33) The client at 34 weeks gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the client understands the treatment being administered?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. The baby needs to be monitored to check the heart rate.

2. My bowel has probably been lacerated by the knife.

3. I might need an ultrasound to look at the baby.

4. The catheter in my bladder will prevent urinary complications.

5. The IV in my arm will replace the amniotic fluid if it is leaking.

Answer: 1, 3

Explanation: 1. Ongoing assessments of trauma include evaluation of uterine tone, contractions and tenderness, fundal height, fetal heart rate, intake and output and other indicators of shock, normal postoperative evaluation in those women requiring surgery, determination of neurologic status, and assessment of mental outlook and anxiety level.

3. In cases of noncatastrophic trauma, where the mothers life is not directly threatened, fetal monitoring for 4 hours should be sufficient if there is no vaginal bleeding, uterine tenderness, contractions, or leaking amniotic fluid.

Page Ref: 402

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7 Relate the impact of major trauma during pregnancy to the nursing care of the woman and her fetus.

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34) A client is admitted to the labor suite. It is essential that the nurse assess the womans status in relation to which infectious diseases?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Chlamydia trachomatis

2. Rubeola

3. Varicella

4. Group B streptococcus

5. Acute pyelonephritis

Answer: 1, 4, 5

Explanation: 1. The infant may develop chlamydial pneumonia and Chlamydia trachomatis may be responsible for premature labor and fetal death. Chlamydial infection should be assessed.

4. Women may transmit GBS to their fetus in utero or during childbirth. GBS is a leading infectious cause of neonatal sepsis and mortality and should be assessed.

5. Acute pyelonephritis should be assessed as there is an increased risk of premature birth and intrauterine growth restriction (IUGR).

Page Ref: 397, 399

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5 Contrast the effects of various infections on the pregnant woman and her unborn child.

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35) The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Prematurity

2. Maternal intrapartum fever

3. Membranes ruptured for longer than 18 hours

4. A previously infected infant with GBS disease

5. An older mother having her first baby

Answer: 1, 2, 3, 4

Explanation: 1. Prematurity is a risk factor.

2. Maternal intrapartum fever is a risk factor.

3. Prolonged rupture of membranes is a risk factor.

4. A previously infected infant increases the risk.

Page Ref: 397

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5 Contrast the effects of various infections on the pregnant woman and her unborn child.

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