Sie sind auf Seite 1von 11

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 52
Question 1
Type: MCMA
The nurse working in an obstetrician's office determines that which clients have high-risk pregnancy? Select all
that apply.
Standard Text: Select all that apply.
1. The woman recovering from a gastrointestinal virus
2. The woman who had a healthy baby six months ago resulting from a healthy pregnancy
3. The woman who lives in an urban area in a high-rise apartment
4. The unmarried 14-year-old woman living in a rural area
5. The woman who drinks one cup of coffee every morning
Correct Answer: 2,4
Rationale 1: The woman who delivered a baby only six months ago is at higher risk because her body has not had
time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural
areas where there might be limited access to health care providers also face greater challenges. A GI virus will not
negatively impact the pregnancy, and those in urban areas have better access to health care. One cup of coffee is
not excessive intake of caffeine.
Rationale 2: The woman who delivered a baby only six months ago is at higher risk because her body has not had
time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural
areas where there might be limited access to health care providers also face greater challenges. A GI virus will not
negatively impact the pregnancy, and those in urban areas have better access to health care. One cup of coffee is
not excessive intake of caffeine.
Rationale 3: The woman who delivered a baby only six months ago is at higher risk because her body has not had
time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural
areas where there might be limited access to health care providers also face greater challenges. A GI virus will not
negatively impact the pregnancy, and those in urban areas have better access to health care. One cup of coffee is
not excessive intake of caffeine.
Rationale 4: The woman who delivered a baby only six months ago is at higher risk because her body has not had
time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural
areas where there might be limited access to health care providers also face greater challenges. A GI virus will not
negatively impact the pregnancy, and those in urban areas have better access to health care. One cup of coffee is
not excessive intake of caffeine.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 5: The woman who delivered a baby only six months ago is at higher risk because her body has not had
time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural
areas where there might be limited access to health care providers also face greater challenges. A GI virus will not
negatively impact the pregnancy, and those in urban areas have better access to health care. One cup of coffee is
not excessive intake of caffeine.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: List risk factors that create a high-risk pregnancy.
Question 2
Type: MCSA
What information will the nurse want to question specifically for the adolescent who was just informed she is
pregnant?
1. Last menstrual period
2. Dietary habits
3. Use of substances such as drugs, alcohol, and tobacco
4. Previous reproductive history
Correct Answer: 3
Rationale 1: Adolescents have a higher rate of substance abuse, and should be questioned specifically regarding
use of drugs, alcohol, and tobacco, as these can have a negative impact on the outcome of the fetus. All pregnant
women will be asked about last menstrual period, diet, and reproductive history. LMP is of less importance with
the young adolescent, whose periods tend to be irregular, and cannot be counted on to indicate due date.
Rationale 2: Adolescents have a higher rate of substance abuse, and should be questioned specifically regarding
use of drugs, alcohol, and tobacco, as these can have a negative impact on the outcome of the fetus. All pregnant
women will be asked about last menstrual period, diet, and reproductive history. LMP is of less importance with
the young adolescent, whose periods tend to be irregular, and cannot be counted on to indicate due date.
Rationale 3: Adolescents have a higher rate of substance abuse, and should be questioned specifically regarding
use of drugs, alcohol, and tobacco, as these can have a negative impact on the outcome of the fetus. All pregnant
women will be asked about last menstrual period, diet, and reproductive history. LMP is of less importance with
the young adolescent, whose periods tend to be irregular, and cannot be counted on to indicate due date.
Rationale 4: Adolescents have a higher rate of substance abuse, and should be questioned specifically regarding
use of drugs, alcohol, and tobacco, as these can have a negative impact on the outcome of the fetus. All pregnant
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

women will be asked about last menstrual period, diet, and reproductive history. LMP is of less importance with
the young adolescent, whose periods tend to be irregular, and cannot be counted on to indicate due date.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify the physical, psychological, and sociologic risks faced by the adolescent who is
pregnant.
Question 3
Type: MCSA
The nurse working in an obstetrician's office receives a call from a 13-year-old girl who is 28 weeks pregnant
reporting severe back pain that is constant and rated as a 7 on a 1-10 scale. The nurse will:
1. Tell the client to come to the obstetrician's office immediately.
2. Instruct the client to lie down after taking two acetaminophen (Tylenol).
3. Make an appointment for the client to be seen later this afternoon.
4. Tell the client to take a laxative and call back if pain not relieved.
Correct Answer: 1
Rationale 1: Because the young adolescent is at increased risk for pregnancy complications, the client should be
told to come to the office for evaluation. The pain might be benign, resulting from shifts in the center of gravity
secondary to the growing abdomen, or it could be serious, indicating preterm labor or a urinary tract infection.
The client must be seen and evaluated to determine cause.
Rationale 2: Because the young adolescent is at increased risk for pregnancy complications, the client should be
told to come to the office for evaluation. The pain might be benign, resulting from shifts in the center of gravity
secondary to the growing abdomen, or it could be serious, indicating preterm labor or a urinary tract infection.
The client must be seen and evaluated to determine cause.
Rationale 3: Because the young adolescent is at increased risk for pregnancy complications, the client should be
told to come to the office for evaluation. The pain might be benign, resulting from shifts in the center of gravity
secondary to the growing abdomen, or it could be serious, indicating preterm labor or a urinary tract infection.
The client must be seen and evaluated to determine cause.
Rationale 4: Because the young adolescent is at increased risk for pregnancy complications, the client should be
told to come to the office for evaluation. The pain might be benign, resulting from shifts in the center of gravity
secondary to the growing abdomen, or it could be serious, indicating preterm labor or a urinary tract infection.
The client must be seen and evaluated to determine cause.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify the physical, psychological, and sociologic risks faced by the adolescent who is
pregnant.
Question 4
Type: MCSA
The nurse admits a woman who is 8 weeks pregnant who has a history of gestational diabetes with her first
pregnancy. What diagnostic test does the nurse anticipate the physician will order for this client?
1. Indirect Coombs' test
2. Maternal hemoglobin
3. Glucose tolerance test
4. Fetal L/S ratio
Correct Answer: 3
Rationale 1: The woman who became diabetic with her last pregnancy is at risk for gestational diabetes with this
pregnancy as well, and will need to be tested at 24 weeks by performing a glucose tolerance test. Other tests may
also be ordered, but they are less likely than the GTT.
Rationale 2: The woman who became diabetic with her last pregnancy is at risk for gestational diabetes with this
pregnancy as well, and will need to be tested at 24 weeks by performing a glucose tolerance test. Other tests may
also be ordered, but they are less likely than the GTT.
Rationale 3: The woman who became diabetic with her last pregnancy is at risk for gestational diabetes with this
pregnancy as well, and will need to be tested at 24 weeks by performing a glucose tolerance test. Other tests may
also be ordered, but they are less likely than the GTT.
Rationale 4: The woman who became diabetic with her last pregnancy is at risk for gestational diabetes with this
pregnancy as well, and will need to be tested at 24 weeks by performing a glucose tolerance test. Other tests may
also be ordered, but they are less likely than the GTT.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Describe tests used to assess maternal and fetal well-being.
Question 5
Type: MCSA
The nurse working in an obstetrician's office admits a woman who is 12 weeks pregnant and began spotting this
morning. The nurse anticipates the physician will:
1. Order bedrest for several days.
2. Perform a dilatation and curettage.
3. Perform a cerclage.
4. Perform a salpingectomy.
Correct Answer: 1
Rationale 1: With only spotting, the client may be placed on bedrest or just instructed to reduce activity levels
until bleeding stops. A D and C would not be performed unless bleeding were heavy and incomplete abortion
suspected.
Rationale 2: With only spotting, the client may be placed on bedrest or just instructed to reduce activity levels
until bleeding stops. A D and C would not be performed unless bleeding were heavy and incomplete abortion
suspected.
Rationale 3: With only spotting, the client may be placed on bedrest or just instructed to reduce activity levels
until bleeding stops. A D and C would not be performed unless bleeding were heavy and incomplete abortion
suspected.
Rationale 4: With only spotting, the client may be placed on bedrest or just instructed to reduce activity levels
until bleeding stops. A D and C would not be performed unless bleeding were heavy and incomplete abortion
suspected.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss complications of pregnancy, their treatment, and nursing care.
Question 6
Type: MCSA
The nurse working in an Emergency Department admits a woman whose last menstrual period was seven weeks
ago with acute severe lower right-sided abdominal pain with heavy menstrual bleeding. The client is very pale,
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

and vital signs reveal a pulse of 122 and blood pressure of 86/52. The nurse's priority action while waiting for the
physician is to:
1. Inform the client she has an ectopic pregnancy.
2. Place the client in Trendelenburg position.
3. Initiate an intravenous line.
4. Obtain a complete medical and surgical history.
Correct Answer: 2
Rationale 1: While the cause of the bleeding might be an ectopic pregnancy, it is not the nurse's role to diagnose
the client, but placing her in Trendelenburg position might help to reverse shock symptoms. The nurse can prepare
to initiate an IV, but it cannot be placed until the doctor orders it. A medical and surgical history may be obtained,
but it is not the priority.
Rationale 2: While the cause of the bleeding might be an ectopic pregnancy, it is not the nurse's role to diagnose
the client, but placing her in Trendelenburg position might help to reverse shock symptoms. The nurse can prepare
to initiate an IV, but it cannot be placed until the doctor orders it. A medical and surgical history may be obtained,
but it is not the priority.
Rationale 3: While the cause of the bleeding might be an ectopic pregnancy, it is not the nurse's role to diagnose
the client, but placing her in Trendelenburg position might help to reverse shock symptoms. The nurse can prepare
to initiate an IV, but it cannot be placed until the doctor orders it. A medical and surgical history may be obtained,
but it is not the priority.
Rationale 4: While the cause of the bleeding might be an ectopic pregnancy, it is not the nurse's role to diagnose
the client, but placing her in Trendelenburg position might help to reverse shock symptoms. The nurse can prepare
to initiate an IV, but it cannot be placed until the doctor orders it. A medical and surgical history may be obtained,
but it is not the priority.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss complications of pregnancy, their treatment, and nursing care.
Question 7
Type: MCSA
The nurse admits a client who is 30 weeks pregnant who reports she began having vaginal bleeding this morning.
The client denies any pain, and the abdomen is not tender. Which of the following diagnosis would be consistent
with these assessment findings?
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Abruptio placentae
2. Placenta previa
3. Ectopic pregnancy
4. Gestational trophoblastic disease
Correct Answer: 2
Rationale 1: The classic symptom of placenta previa is painless bleeding, usually in the last trimester of
pregnancy, as the cervix begins to dilate, pulling away from the placenta that covers part of or the entire cervix.
Rationale 2: The classic symptom of placenta previa is painless bleeding, usually in the last trimester of
pregnancy, as the cervix begins to dilate, pulling away from the placenta that covers part of or the entire cervix.
Rationale 3: The classic symptom of placenta previa is painless bleeding, usually in the last trimester of
pregnancy, as the cervix begins to dilate, pulling away from the placenta that covers part of or the entire cervix.
Rationale 4: The classic symptom of placenta previa is painless bleeding, usually in the last trimester of
pregnancy, as the cervix begins to dilate, pulling away from the placenta that covers part of or the entire cervix.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss complications of pregnancy, their treatment, and nursing care.
Question 8
Type: MCSA
The nurse admits a client who is 12 weeks pregnant who reports brownish drainage from the vagina. The client
has recently been discharged from the hospital, where she was admitted for rehydration secondary to hyperemesis
gravidarum. The technician performs an ultrasound and shows the image to the physician, pointing out there is no
fetus growing in the uterus. The physician orders a STAT serum quantitative HCG, which returns with higherthan-expected values. The nurse concludes that the client:
1. Is further into the pregnancy than expected.
2. Is pregnant with twins.
3. Is experiencing a threatened abortion.
4. Has gestational trophoblastic disease.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 4
Rationale 1: Clients with gestational trophoblastic disease have an increase in trophoblast cell production with
higher-than-normal HCG levels often resulting in hyperemesis gravidarum. It is not uncommon for clients to have
vaginal bleeding resembling prune juice, although it can also be bright red in color.
Rationale 2: Clients with gestational trophoblastic disease have an increase in trophoblast cell production with
higher-than-normal HCG levels often resulting in hyperemesis gravidarum. It is not uncommon for clients to have
vaginal bleeding resembling prune juice, although it can also be bright red in color.
Rationale 3: Clients with gestational trophoblastic disease have an increase in trophoblast cell production with
higher-than-normal HCG levels often resulting in hyperemesis gravidarum. It is not uncommon for clients to have
vaginal bleeding resembling prune juice, although it can also be bright red in color.
Rationale 4: Clients with gestational trophoblastic disease have an increase in trophoblast cell production with
higher-than-normal HCG levels often resulting in hyperemesis gravidarum. It is not uncommon for clients to have
vaginal bleeding resembling prune juice, although it can also be bright red in color.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss complications of pregnancy, their treatment, and nursing care.
Question 9
Type: MCSA
The nurse is providing client teaching for a young woman who was recently informed she is pregnant. The client
has a history of cardiomyopathy secondary to a pediatric infection. In addition to routine prenatal teaching, the
nurse will instruct this client to immediately report:
1. Shortness of breath, sudden weight gain, or dependent edema.
2. Weight loss, hematuria, or excessive urine output.
3. Headaches, vaginal bleeding, or unusual food cravings.
4. Vomiting, fatigue, or insomnia.
Correct Answer: 1
Rationale 1: Shortness of breath, sudden weight gain, or dependent edema might signal the onset of congestive
heart failure, which could result from the increased strain placed on the heart by the pregnancy. The client must be
alert for these symptoms and report them immediately.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: Shortness of breath, sudden weight gain, or dependent edema might signal the onset of congestive
heart failure, which could result from the increased strain placed on the heart by the pregnancy. The client must be
alert for these symptoms and report them immediately.
Rationale 3: Shortness of breath, sudden weight gain, or dependent edema might signal the onset of congestive
heart failure, which could result from the increased strain placed on the heart by the pregnancy. The client must be
alert for these symptoms and report them immediately.
Rationale 4: Shortness of breath, sudden weight gain, or dependent edema might signal the onset of congestive
heart failure, which could result from the increased strain placed on the heart by the pregnancy. The client must be
alert for these symptoms and report them immediately.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify medical conditions that are complicated by pregnancy and appropriate measures to
support the pregnant woman.
Question 10
Type: MCSA
The nurse is providing prenatal teaching to a client who just learned she is pregnant. The client asks, "Will my
baby be born with HIV because I am HIV-positive?" The nurse's most accurate response is:
1. "Yes, because HIV is transmitted through the shared maternal-fetal circulation."
2. "Yes, because the baby will come in contact with your blood during delivery."
3. "Not necessarily, if you take your prescribed ZDV and deliver by C-section."
4. "No, the doctor will make sure to take all the necessary precautions to prevent that."
Correct Answer: 3
Rationale 1: While HIV transmission to the fetus can occur during pregnancy, the greatest risk is during delivery.
If the mother takes ZDV and delivers by cesarean section, the risk of fetal transmission is greatly reduced, and
there is a good chance the baby will test negative for HIV.
Rationale 2: While HIV transmission to the fetus can occur during pregnancy, the greatest risk is during delivery.
If the mother takes ZDV and delivers by cesarean section, the risk of fetal transmission is greatly reduced, and
there is a good chance the baby will test negative for HIV.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: While HIV transmission to the fetus can occur during pregnancy, the greatest risk is during delivery.
If the mother takes ZDV and delivers by cesarean section, the risk of fetal transmission is greatly reduced, and
there is a good chance the baby will test negative for HIV.
Rationale 4: While HIV transmission to the fetus can occur during pregnancy, the greatest risk is during delivery.
If the mother takes ZDV and delivers by cesarean section, the risk of fetal transmission is greatly reduced, and
there is a good chance the baby will test negative for HIV.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify medical conditions that are complicated by pregnancy and appropriate measures to
support the pregnant woman.
Question 11
Type: MCSA
The nurse is caring for a client diagnosed with a high-risk pregnancy related to multiple pregnancy. An
appropriate nursing goal for this client is:
1. Client will carry the pregnancy to full term.
2. Client will relate strategies for prolonging pregnancy and reducing complications.
3. Client will experience no complications related to multiple birth.
4. Client will deliver healthy babies at term.
Correct Answer: 3
Rationale 1: While it might be unreasonable to expect that this client will go to full term, depending on the
number of babies she is carrying, it is reasonable to make sure she is well informed on how to prolong the
pregnancy and take care of herself in order to reduce the risk of complications.
Rationale 2: While it might be unreasonable to expect that this client will go to full term, depending on the
number of babies she is carrying, it is reasonable to make sure she is well informed on how to prolong the
pregnancy and take care of herself in order to reduce the risk of complications.
Rationale 3: While it might be unreasonable to expect that this client will go to full term, depending on the
number of babies she is carrying, it is reasonable to make sure she is well informed on how to prolong the
pregnancy and take care of herself in order to reduce the risk of complications.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: While it might be unreasonable to expect that this client will go to full term, depending on the
number of babies she is carrying, it is reasonable to make sure she is well informed on how to prolong the
pregnancy and take care of herself in order to reduce the risk of complications.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Describe nursing care for the woman with a high-risk pregnancy.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.