NURS 1235 Chapter 13: Adaptations to Pregnancy McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition
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Course
NURS 1235
Institution
NURS 1235
MULTIPLE CHOICE
1. A pregnant woman’s mother is worried that her daughter is not “big enough” at 20 weeks. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman’s umbilicus. What should the nurse report to the woman and her mother?
a. “The body of th...
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NURS 1235
Chapter 13: Adaptations to Pregnancy
McKinney: Evolve Resources for Maternal-Child Nursing,
5th Edition
MULTIPLE CHOICE
1. A pregnant woman’s mother is worried that her daughter is not “big enough” at 20 weeks. The
nurse palpates and measures the fundal height at 20 cm, which is even with the woman’s
umbilicus. What should the nurse report to the woman and her mother?
a.
“The body of the uterus is at the belly button level, just where it should be at this
time.”
b.
“You’re right. We’ll inform the practitioner immediately.”
c.
“When you come for next month’s appointment, we’ll check you again to
make sure that the baby is growing.”
d.
“Lightening has occurred, so the fundal height is lower than expected.”
ANS: A
At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in
a predictable pattern, obstetric nurses should know that the uterus of 20 weeks of gestation is
located at the level of the umbilicus. There is no need to inform the practitioner. The nurse
should reassure both mother and patient that the findings are normal. The descent of the fetal
head (lightening) occurs in late pregnancy.
PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 214 | p. 229 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. While the nurse assesses the vital signs of a pregnant woman in her third trimester, the
patient complains of feeling faint, dizzy, and agitated. Which nursing intervention is
appropriate?
a.
Have the patient stand up and retake her blood pressure.
b.
Have the patient sit down and hold her arm in a dependent position.
c.
Have the patient lie supine for 5 minutes and recheck her blood pressure on both
arms.
d.
Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
ANS: D
Blood pressure is affected by positions during pregnancy. The supine position may cause
occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral
recumbent position alleviates pressure on the blood vessels and quickly corrects supine
hypotension. Pressures are significantly higher when the patient is standing. This option
causes an increase in systolic and diastolic pressures. The arm should be supported at the
same level of the heart. The supine position may cause occlusion of the vena cava and
descending aorta, creating hypotension.
3. A pregnant woman has come to the emergency department with complaints of nasal
congestion and epistaxis. What action by the nurse is best?
a.
Refer the patient to an ear, nose, and throat specialist.
, b.
Explain that nasal stuffiness and nosebleeds are caused by a decrease
in progesterone.
c.
Attach the woman to a cardiac monitor, and draw blood for hemoglobin
and hematocrit.
d.
Teach that the increased blood supply to the mucous membranes and can result
in congestion and nosebleeds.
ANS: D
As capillaries become engorged, the upper respiratory tract is affected by the subsequent
edema and hyperemia, which causes these conditions, seen commonly during pregnancy. No
referral is needed. The patient does not need to be attached to a cardiac monitor or have lab
drawn. The patient should be taught that estrogen causes these changes, not progesterone.
4. Which finding in the urine analysis of a pregnant woman is considered a variation of normal?
a.
Proteinuria
b.
Glycosuria
c.
Bacteria
d.
Ketonuria
ANS: B
Small amounts of glucose may indicate “physiologic spilling,” which occurs because the
filtered load exceeds the renal tubules’ ability to absorb them. The presence of protein could
indicate kidney disease or preeclampsia. Urinary tract infections are associated with bacteria
in the urine. An increase in ketones indicates that the patient is exercising too strenuously or
has an inadequate fluid and food intake.
5. Which suggestion is appropriate for the pregnant woman who is experiencing nausea and
vomiting?
a.
Eat only three meals a day so the stomach is empty between meals.
b.
Drink plenty of fluids with each meal.
c.
Eat dry crackers or toast before arising in the morning.
d.
Drink coffee or orange juice immediately on arising in the morning.
ANS: C
This will assist with the symptoms of morning sickness. It is also important for the woman to
arise slowly. Instruct the woman to eat five to six small meals rather than three full meals per
day. Nausea is more intense when the stomach is empty. Fluids should be taken separately
from meals. Fluids overstretch the stomach and may precipitate vomiting. Coffee and orange
juice stimulate acid formation in the stomach. It is best to suggest eating dry carbohydrates
when rising in the morning.
, 6. Which statement related to changes in the breasts during pregnancy is the most accurate?
a.
During the early weeks of pregnancy there is decreased sensitivity.
b.
Nipples and areolae become more pigmented.
c.
Montgomery tubercles are no longer visible around the nipples.
d.
Venous congestion of the breasts is more visible in the multiparous woman.
ANS: B
Nipples and areolae become more pigmented, and the nipples become more erectile and may
express colostrum. Fullness, heightened sensitivity, tingling, and heaviness of the breasts
occur in the early weeks of gestation in response to increased levels of estrogen and
progesterone. Montgomery tubercles may be seen around the nipples. These sebaceous glands
may have a protective role in that they keep the nipples lubricated for breastfeeding. Venous
congestion in the breasts is more obvious in primigravidas.
7. A student nurse reads a patient’s chart and sees the term “striae gravidarum,” The student asks
the registered nurse what this means. What response by the nurse is accurate?
a.
Stretch marks on the abdomen and breasts
b.
Dark pigmentation on the woman’s face
c.
Bluish-purple discoloration of the vagina and labia
d.
Reddened bleeding gums in a pregnant woman
ANS: A
Stretch marks occurring on the abdomen and/or breasts of a pregnant woman are called striae
gravidarum. Dark pigmentation on the face is known as melisma, chloasma, or the mask of
pregnancy. The bluish tint to the vagina and labia is known as Chadwick’s sign. Reddened and
bleeding gums are known as gingivitis in both pregnant and non-pregnant women.
8. The maternity nurse understands that vascular volume increases 40% to 60% during
pregnancy to
a.
compensate for decreased renal plasma flow.
b.
provide adequate perfusion of the placenta.
c.
eliminate metabolic wastes of the mother.
d.
prevent maternal and fetal dehydration.
ANS: B
The primary function of increased vascular volume is to transport oxygen and nutrients to the
fetus via the placenta. Renal plasma flow increases during pregnancy. Assisting with pulling
metabolic wastes from the fetus for maternal excretion is one purpose of the increased
vascular volume. However, this answer is not the best because it doesn’t explain the overall
purpose and only includes one purpose. Prevention of dehydration is not the reason for
increased vascular volume.
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