Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs My Nursing Test Banks

Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions?

a. Hyperalimentation
b. IV fluids and electrolyte replacement
c. Hormone replacement therapy
d. Vitamin supplements

ANS: B

Medical treatment is aimed at meeting fluid and electrolyte replacement.

PTS: 1 DIF: Cognitive Level: Application REF: Page 878

OBJ:1TOP:Hyperemesis gravidarum

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

2.A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse?

a. A large for gestational age infant
b. Anorexia nervosa
c. Preterm delivery
d. Maternal or fetal death

ANS: D

If untreated, hyperemesis gravidarum can result in maternal or fetal death.

PTS: 1 DIF: Cognitive Level: Application REF: Page 879

OBJ:1TOP:Hyperemesis gravidarum

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3.How should twins who share a placenta and come from one fertilized ovum be identified?

a. Dizygotic
b. Trizygotic
c. Genetically different
d. Monozygotic

ANS: D

Monozygotic twins, also known as identical twins, originate from one fertilized ovum and share a placenta. Monozygotic twins carry the same genetic code. Dizygotic twins are the result of two separate ova being fertilized at the same time.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 879

OBJ:1TOP:Multifetal pregnancy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

4.What complication of delivery should the nurse expect with the birth of multiple fetuses?

a. An ectopic tendency
b. Difficulty with breastfeeding
c. A vaginal delivery
d. Loss of uterine tone

ANS: D

Delivery of multiple fetuses is often complicated by loss of uterine tone. Oftentimes multiple fetuses are delivered by cesarean. An ectopic tendency would present before delivery. While it can be difficult to breastfeed multiple infants, this does not relate to the delivery.

PTS: 1 DIF: Cognitive Level: Application REF: Page 879

OBJ:1TOP:High-risk pregnancy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5.A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient?

a. Long-term bed rest
b. Episodes of extreme hypertension
c. Surgery to remove the embryo/fetus
d. Treatment for dehydration

ANS: C

An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention.

PTS: 1 DIF: Cognitive Level: Application REF: Page 881

OBJ:1TOP:Ectopic pregnancy

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

6.What percent of first-trimester  pregnancies spontaneously abort?

a. 5% to 10%
b. 10% to15%
c. 20% to 25%
d. 40% to 50%

ANS: B

It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous abortion.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 882

OBJ: 1 TOP: Abortions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

7.What symptom, no matter what stage of pregnancy, should be reported immediately?

a. Backache
b. Urinary frequency
c. Vaginal bleeding
d. Uterine tightening

ANS: C

Women should be instructed to contact their physician if any bleeding occurs during pregnancy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 884

OBJ:2TOP:Vaginal bleeding

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

8.A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect?

a. Abruptio placentae
b. Hemorrhage
c. Placenta previa
d. Placentitis

ANS: C

Placenta previa is a serious condition that consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy. The major symptoms of abruptio placentae are severe abdominal pain and uterine rigidity.

PTS: 1 DIF: Cognitive Level: Application REF: Page 884

OBJ:2TOPlacenta previa

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9.A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain?

a. Placenta previa
b. Appendicitis
c. Ectopic pregnancy
d. Abruptio placentae

ANS: D

The major symptoms of abruptio placentae are severe pain and a rigid abdomen. Placenta previa consists of painless bleeding.  Appendicitis is not usually accompanied by a rigid abdomen. Symptoms of an ectopic pregnancy would usually occur in the first trimester.

PTS: 1 DIF: Cognitive Level: Application REF: Page 885

OBJ:2TOP:Abruptio placentae

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

10.A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient?

a. Prone position
b. Trendelenburg position
c. Supine position
d. Modified side-lying position

ANS: D

A modified side-lying position facilitates uterine-placental perfusion.

PTS: 1 DIF: Cognitive Level: Application REF: Page 886

OBJ:2TOP:Abruptio placentae

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11.A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect?

a. Allergy
b. Protein deficiency
c. Circulatory problem
d. Gestational hypertension

ANS: D

Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension (PIH), is a disease encountered during pregnancy or early in the puerperium, characterized by increasing hypertension, proteinuria, and generalized edema. These signs generally appear after the 20th week of pregnancy.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 889

OBJ:4TOPregnancy-induced hypertension (PIH)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12.What is the cause of gestational hypertension?

a. Too much salt
b. A toxin
c. Unknown
d. Diabetes

ANS: C

The cause of gestational hypertension is unknown.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 889

OBJ:4TOPregnancy-induced hypertension (PIH)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

13.What should the nurse hope to identify by keeping a record of a patients blood pressure during prenatal visits?

a. Ketoacidosis
b. Placenta previa
c. Gestational diabetes
d. Gestational hypertension

ANS: D

Blood pressure should be assessed routinely during pregnancy, because symptoms of gestational hypertension include hypertension.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 889

OBJ:4TOPregnancy-induced hypertension (PIH)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

14.The nurse is assessing a kick count for a patient with gestational hypertension. What result should be a cause for concern?

a. Less than three kicks per hour
b. Less than five kicks per hour
c. Less than seven kicks per hour
d. Less than nine kicks per hour

ANS: A

A kick count of fewer than three per hour is considered serious and a cause for concern.

PTS: 1 DIF: Cognitive Level: Application REF: Page 891

OBJ:3TOPregnancy-induced hypertension (PIH)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15.When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid?

a. Contact with an infected person
b. Emptying cat litter boxes bare-handed
c. Having unprotected sex
d. Eating excessive amounts of shellfish

ANS: B

A pregnant woman should wear gloves whenever having contact with cat feces as this is a possible source of toxoplasmosis infection.

PTS: 1 DIF: Cognitive Level: Application REF: Page 895, Box 28-5

OBJ: 6 TOP: Infections KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

16.What is a major complication of gestational diabetes that affects the infant?

a. Lack of nutrition
b. Dehydration
c. Hypoglycemia
d. Hyperglycemia

ANS: C

A result of gestational diabetes is neonatal hypoglycemia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 898

OBJ: 1 TOP: Diabetes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17.A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the insulin necessary?

a. The growing baby will require more glucose.
b. Oral hypoglycemic agents may be teratogenic.
c. Increased hormone levels raise blood glucose.
d. Oral hypoglycemics do not reach the fetus.

ANS: B

Oral hypoglycemics are discontinued because of teratogenic effects.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 898

OBJ: 5 TOP: Diabetes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18.Why is the fetus dependent on the mother for glucose control?

a. The insulin requirements are higher.
b. Insulin is destroyed by the placenta.
c. Insulin does not cross the placenta.
d. Insulin is absorbed by the fetus.

ANS: C

Insulin will not cross the placenta, but high glucose levels do. Therefore, it is imperative that the mother control glucose levels.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 901

OBJ: 5 TOP: Diabetes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

19.A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered?

a. Oxygen administration
b. Administering large amount of IV fluids
c. Positioning the patient on her back
d. Encouraging activity between contractions

ANS: A

Oxygen is administered to increase blood oxygen saturation and decrease the stress on the heart. IV fluid administration is kept to a minimum to prevent fluid overload. The patient would be positioned in a semi-Fowler position to improve circulation. The patient should be encouraged to rest between contractions to conserve energy.

PTS: 1 DIF: Cognitive Level: Application REF: Page 902

OBJ:12TOP:Cardiovascular defects

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

20.A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem?

a. Calcium deficit
b. Cephalopelvic disproportion
c. Bleeding tendency
d. Low hemoglobin levels

ANS: B

There are several physiological concerns for pregnant adolescents, including cephalopelvic disproportion.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 903

OBJ:7TOP:Adolescent pregnancy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

21.When should the gestational age of the infant be determined?

a. Within 5 to 10 minutes of delivery
b. Within 1 to 2 hours of delivery
c. Within 2 to 8 hours of delivery
d. Within 12 to 24 hours of delivery

ANS: C

The gestational age tests are done within 2 to 8 hours of delivery.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 908

OBJ:9TOP:Gestational age

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

22.The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant?

a. 20 to 37 completed weeks of pregnancy
b. 38 to 41 completed weeks of pregnancy
c. 14 to 36 completed weeks of pregnancy
d. 42 or more completed weeks of pregnancy

ANS: A

The lungs of preterm infants have not fully developed; therefore, they have problems with oxygenation. Preterm infants also lack subcutaneous fat. The gestational age of the preterm is classified as 20 to 37 complete weeks of pregnancy.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 908

OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

23.Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants?

a. 1 to 2 times
b. 2 to 3 times
c. 3 to 4 times
d. 4 to 5 times

ANS: C

The morbidity and mortality rate for preterm infants is higher by 3 to 4 times that of an older infant of similar weight.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 908

OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

24.A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant?

a. Full term
b. Small for gestational age
c. Preterm
d. Post-term

ANS: C

Preterm infant posture is froglike, the muscle tone is weak, and the ears are easily folded.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 909

OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

25.An infant born to a diabetic mother should be closely monitored for the presence of what condition?

a. Hyperglycemia
b. Hypercalcemia
c. Hypoglycemia
d. Cardiac abnormalities

ANS: C

The infant of a diabetic mother will frequently exhibit hypoglycemia, hypocalcemia, perinatal asphyxia, congenital abnormalities, and respiratory difficulties.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 912

OBJ: 11 TOP: Diabetes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

26.A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies?

a. Rh-negative blood cells
b. Rh-positive blood cells
c. Rh-negative antibodies
d. Rh-positive antibodies

ANS: D

If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced after delivery of an Rh-positive baby. If the baby is Rh negative, no antibodies will be produced.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 912

OBJ:10TOP:Hemolytic disease

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

27.The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection?

a. Iron
b. Vitamin B12
c. RhoGAM
d. Type O blood

ANS: C

RhoGAM prevents the development of naturally occurring maternal antibodies.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 913

OBJ:10TOP:Hemolytic disease

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

28.The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth?

a. Within normal limits
b. Pathologic
c. A result of iron deficiency
d. Indicating possible hepatitis

ANS: B

Jaundice observed at birth is considered an indicator of a pathologic condition, erythroblastosis fetalis. It is considered abnormal.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 912

OBJ:10TOP:Hemolytic disease

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

29.What test is used to identify the maternal level of Rh antibodies in the mothers blood?

a. Indirect Coombs test
b. Hemolytic test
c. Rh antibody test
d. Direct Coombs test

ANS: A

The indirect Coombs test measures the maternal level of antibodies.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 912

OBJ:3TOP:Hemolytic disease

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

30.A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy?

a. It is initiated when the bilirubin level reaches 5 mg/dL.
b. It converts bilirubin to a water-soluble form to be excreted in the urine.
c. It changes bilirubin to a bile salt to be excreted through the bowel.
d. It requires eye patches to remain in place 24 hours a day.

ANS: B

Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches are worn during therapy, but removed for feeding, bathing, and socialization.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 913

OBJ:10TOP:Hemolytic disease

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

31.Why do alcohol and illegal drugs endanger the fetus?

a. Both are absorbed into the bloodstream.
b. Both affect the mother.
c. Both cross the placental barrier.
d. Both increase the heart rate of the fetus.

ANS: C

Alcohol and illicit drugs cross the placental barrier and affect the fetus.

PTS: 1 DIF: Cognitive Level: Application REF: Page 914

OBJ:8TOP:Fetal risk from drugs

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

32.Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus?

a. Fetal dependency
b. Fetal immaturity
c. Malnutrition dependency
d. Fetal alcohol syndrome

ANS: D

Use of alcohol may result in multiple anomalies called fetal alcohol syndrome. The fetus may also be born with alcohol dependency and immaturity, but the characteristics noted are specific for fetal alcohol syndrome.

PTS: 1 DIF: Cognitive Level: Application REF: Page 915, Table 28-4

OBJ: 8 TOP: Fetal risk KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

33.What should be specifically monitored in a patient who is hospitalized with gestational hypertension?

a. Blood sugar
b. Temperature
c. Level of consciousness
d. Deep tendon reflexes

ANS: D

If the patient is hospitalized for gestational hypertension, deep tendon reflexes are monitored. The blood sugar, temperature, and LOC will also be monitored, but they are not the priority in the hypertensive patient.

PTS: 1 DIF: Cognitive Level: Application REF: Page 890

OBJ: 4 TOP: Eclampsia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

34.What is the antidote for magnesium sulfate toxicity?

a. Vitamin K
b. Calcium gluconate
c. Potassium sulfate
d. Calcium carbonate

ANS: B

The antidote for magnesium sulfate toxicity is calcium gluconate.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 892, Box 28-4

OBJ:11TOP:Maternal risk

KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment

35.What is a prominent feature of postpartum depression?

a. Failure to thrive
b. Rejection of the infant
c. Inability to care for the baby
d. Problems with the babys father

ANS: B

A prominent feature of PPD is rejection of the infant.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 916

OBJ:1TOPostpartum depression (PPD)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

36.What is the usual treatment for severe postpartum depression?

a. Improved nutrition
b. Vitamin therapy
c. Pharmacologic interventions
d. Support group therapy

ANS: C

Support therapy is not enough for major PPD. Pharmacologic interventions are needed in most instances.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 916

OBJ:1TOPostpartum depression (PPD)

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

37.A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all that apply.)

a. You have nothing to worry about. You will be disease free before you deliver.
b. The tuberculosis can be transmitted to the fetus in rare occurrences.
c. Your newborn will be tested for tuberculosis after delivery.
d. There is no approved treatment for the infant if she tests positive for the disease.
e. You will not be able to hold your newborn until you have been cleared according to the health department guidelines.

ANS: B, C, E

TB can be transmitted to a fetus in the womb. Newborns of infected mothers are skin tested for TB after birth and treated if the skin test is positive. Mothers who have TB are not allowed to have exposure to their newborn until they have been cleared according to the health department standards.

PTS: 1 DIF: Cognitive Level: Application REF: Page 897

OBJ:13TOPulmonary tuberculosis

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

COMPLETION

38.Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of _____________ ______________ _________________.

ANS:

disseminated intravascular coagulation (DIC)

disseminated intravascular coagulation

DIC

DIC is characterized by dyspnea, chest pain, and uncontrolled bleeding.

PTS: 1 DIF: Cognitive Level: Application REF: Page 887

OBJ: 2 TOP: Disseminated intravascular coagulation (DIC)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

39.The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding excessively as she has saturated one peripad in less than ______ minutes.

ANS:

15

fifteen

The saturation of one peripad within 15 minutes is considered to be excessive bleeding.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 888

OBJ:3TOPostpartum hemorrhage

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

40.The nurse explains that severe preeclampsia needs to be controlled because it can develop into another syndrome called _________________.

ANS:

HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets)

HELLP

Hypertension, Elevated Liver enzymes, and Low Platelets

Progressive preeclampsia can develop into HELLP syndrome.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 893

OBJ: 4 TOP: Hypertension, Elevated Liver enzymes, and Low Platelets (HELLP)

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

41.The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a _________ ____________.

ANS:

hydatidiform mole

Hydatidiform moles occur frequently in people who have taken Clomid. The physical changes are similar to a real pregnancy until bleeding occurs and some grapelike clusters are passed.

PTS: 1 DIF: Cognitive Level: Application REF: Page 880

OBJ:3TOP:Hydatidiform mole

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

42.A woman who is 14 weeks pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a _____________ abortion.

ANS:

missed

A missed abortion is initiated by a bleeding episode in which the fetus is not expelled. The uterus begins to shrink, but periods do not resume.

PTS: 1 DIF: Cognitive Level: Application REF: Page 882

OBJ:3TOP:Missed abortion

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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