Which finding in the urine analysis of a pregnant woman is considered a variation of normal? a. Proteinuria b. Glucosuria c. Bacteria in the urine d. Ketones in the urine •ANS: B •Small amounts of glucose may indicate "physiologic spilling." The presence of protein could indicate kidney disease...
NUR 311 - EXAM 2 PRACTICE
QUESTIONS AND ANSWERS
Which finding in the urine analysis of a pregnant woman is considered a variation of
normal?
a. Proteinuria
b. Glucosuria
c. Bacteria in the urine
d. Ketones in the urine ✅•ANS: B
•Small amounts of glucose may indicate "physiologic spilling." The presence of protein
could indicate kidney disease or preeclampsia.
•Bacteria in the urine are associated with urinary tract infections. An increase in ketones
indicates that the client is exercising too strenuously or has inadequate fluid and food
intake.
During the first trimester, the pregnant woman would be most motivated to learn about:
a. Fetal development.
b. Impact of a new baby on family members.
c. Measures to reduce nausea and fatigue so that she can feel better.
d. Location of childbirth preparation and breastfeeding classes. ✅•ANS: C
•During the first trimester, a woman is egocentric and concerned about how she feels.
She is working on the task of accepting her pregnancy.
•Fetal development is a concern during the second trimester when the pregnancy
seems more real. The impact of a new baby on the family would be appropriate topics
for the second trimester, when the fetus becomes "real" as its movements are felt and
its heartbeat is heard. Motivation to learn about childbirth techniques and breastfeeding
is greatest for most women during the third trimester, as the reality of impending birth
and becoming a parent is accepted.
A pregnant woman with a BMI of 22 asks the nurse how she should be gaining weight
during pregnancy. The nurse's best response would be to tell the woman that she
should gain approximately:
a. 1 pound per week throughout the pregnancy.
b. 3.5 pounds during the first trimester, then 1 pound each week until the end of the
pregnancy.
c. 1 pound a week during the first two trimesters, then 2 pounds per week during the
third trimester.
d. A total of 25 to 35 pounds. ✅•ANS: B
•A BMI of 22 represents a normal weight. Therefore a total weight gain for pregnancy
would be about 25 to 35 lb, or about 3.5 lb in the first trimester and about 1 lb per week
during the second and third trimesters. 1 lb per week is too much weight gain for a
,pregnant woman of normal BMI. The weight gain pattern in answer C does not meet the
recommendations. A total weight gain of 25 to 35 lbs is technically right but does not
answer the woman's question usefully.
Which assessment finding would convince the nurse to "hold" the next dose of
magnesium sulfate?
a. Absence of deep tendon reflexes
b. Urinary output of 100 mL total for the previous 2 hours
c. Respiratory rate of 14 breaths/minute
d. Decrease in blood pressure from 160/100 to 140/85 ✅•ANS: A
•Because absence of deep tendon reflexes is a sign of magnesium toxicity, the next
scheduled dose should not be administered. Calcium gluconate is the antidote that
should be administered. An hourly output of less than 30 mL could indicate toxicity. A
respiratory rate of less than 12 breaths/min could indicate toxicity. Decrease in blood
pressure is an expected side effect of magnesium sulfate.
Which intervention may be most helpful for the client experiencing most of her labor
pain in her back?
a. Lying supine with head slightly elevated
b. Having the support person apply firm pressure to the sacrum
c. Sitting upright with the legs straight
d. Having the nurse massage the upper back during a contraction ✅•ANS: B
•Firm pressure against the sacrum, not the upper back, may be helpful in relieving the
discomfort associated with back labor. Ambulation and an upright position are positions
that make contractions more efficient and less painful.
Which occurrence is associated with cervical dilation and effacement?
a. Bloody show
b. False labor
c. Lightening
d. Bladder distention ✅•ANS: A
•As the cervix begins to soften, dilate, and efface, expulsion of the mucus plug that
sealed the cervix during pregnancy occurs. This causes rupture of small cervical
capillaries. Cervical dilation and effacement do not occur with false labor. Lightening is
the descent of the fetus toward the pelvic inlet before labor. Bladder distension occurs
when the bladder is emptied frequently (not emptying bladder all of the way). It may
slow down the decent of the fetus during labor.
A laboring woman is lying in the supine position. What is the most appropriate nursing
action?
a. Ask her to turn to one side.
b. Elevate her feet and legs.
, c. Take her blood pressure.
d. Determine whether there is fetal tachycardia. ✅ANS: A
The woman's supine position may cause the heavy uterus to compress her inferior vena
cava, reducing blood return to her heart and reducing placental blood flow. This problem
is relieved by having her turn onto her side. Elevating her legs will not relieve the
pressure from the inferior vena cava. This position may produce hypotension in the
woman, but the action should be to prevent this from happening, not to assess for the
problem. If the woman is allowed to stay in the supine position, and blood flow to the
placental is reduced significantly, fetal tachycardia may occur. The most appropriate
nursing action is to prevent this from occurring by turning the woman to her side.
The nurse notes a pattern of late decelerations on the fetal monitor. What is the most
appropriate action?
a. Continue observation of this reassuring pattern.
b. Notify the physician or nurse-midwife.
c. Give the woman oxygen by face mask.
d. Place the woman in a Trendelenburg position. ✅•ANS: C
•Late decelerations are associated with reduced placental perfusion. Giving the laboring
woman oxygen increases the oxygen saturation in her blood, making more oxygen
available to the fetus. Late decelerations are not a reassuring pattern; interventions are
needed. Nursing interventions should be initiated before notifying the health care
provider. The Trendelenburg position will not increase the placental perfusion.
What is the most important nursing intervention after the injection of epidural
anesthesia?
a. Monitoring urinary output.
b. Monitoring contractions.
c. Monitoring maternal blood pressure.
d. Monitoring intravenous infusion rate. ✅•ANS: C
•Epidural anesthesia may produce maternal hypotension due to vasodilation. The
mother is prone to bladder distention and this needs to be monitored. However, this
does not become a problem until 1 to 3 hours later. Continuing monitoring of the
contractions is important because they may be altered by the epidural. However, this is
not the most important nursing intervention after the epidural is administered. The
intravenous infusion needs to be maintained before, during, and after the epidural.
However, it is not the most important nursing intervention at this point.
What is the primary risk associated with an amniotomy?
a. Maternal infection.
b. Maternal hemorrhage.
c. Prolapse of the umbilical cord.
d. Separation of the placenta. ✅•ANS: C
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