Maternity and Pediatric Nursing 1st Edition by Ricci, Susan Scott – Test Bank

Ch. 11: Maternal Adaptation During Pregnancy

Page: 290
1. During a vaginal exam, the nurse notes that the cervix has a bluish color. The nurse documents this finding as:
A) Hegar’s sign
B) Goodell’s sign
C) Chadwick’s sign
D) Ortolani’s sign
Ans: C
Response:
Bluish coloration of the cervix is termed Chadwick’s sign. Hegar’s sign refers to the softening of the lower uterine segment or isthmus. Goodell’s sign refers to the softening of the cervix. Ortolani’s sign is a maneuver done to identify developmental dysplasia of the hip in infants.

Page: 292
2. The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time?
A) Dysuria
B) Dyspnea
C) Constipation
D) Urinary frequency
Ans: D
Response:
Lightening refers to the descent of the fetal head into the pelvis and engagement. With this descent, pressure on the diaphragm decreases, easing breathing, but pressure on the bladder increases, leading to urinary frequency. Dysuria might indicate a urinary tract infection. Constipation may occur throughout pregnancy due to decreased peristalsis, but it is unrelated to lightening.

Page: 291
3. A gravida 2 para 1 client in the 10th week of her pregnancy says to the nurse, “I’ve never urinated as often as I have for the past three weeks.” Which response would be most appropriate for the nurse to make?
A) “Having to urinate so often is annoying. I suggest that you watch how much fluid you are drinking and limit it.”
B) “You shouldn’t be urinating this frequently now; it usually stops by the time you’re eight weeks pregnant. Is there anything else bothering you?”
C) “By the time you are 12 weeks pregnant, this frequent urination should no longer be a problem, but it is likely to return toward the end of your pregnancy.”
D) “Women having their second child generally don’t have frequent urination. Are you experiencing any burning sensations?”
Ans: C
Response:
As the uterus grows, it presses on the urinary bladder, causing the increased frequency of urination during the first trimester. This complaint lessens during the second trimester only to reappear in the third trimester as the fetus begins to descend into the pelvis, causing pressure on the bladder.

Page: 291
4. In a client’s seventh month of pregnancy, she reports feeling “dizzy, like I’m going to pass out, when I lie down flat on my back.” The nurse explains that this is due to:
A) Pressure of the gravid uterus on the vena cava
B) A 50% increase in blood volume
C) Physiologic anemia due to hemoglobin decrease
D) Pressure of the presenting fetal part on the diaphragm
Ans: A
Response:
The client is describing symptoms of supine hypotension syndrome, which occurs when the heavy gravid uterus falls back against the superior vena cava in the supine position. The vena cava is compressed, reducing venous return, cardiac output, and blood pressure, with increased orthostasis. The increased blood volume and physiologic anemia are unrelated to the client’s symptoms. Pressure on the diaphragm would lead to dyspnea.

Page: 291
5. A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which of the following would the nurse include?
A) Ankle edema
B) Urinary frequency
C) Backache
D) Hemorrhoids
Ans: B
Response:
The client is in her first trimester and would most likely experience urinary frequency as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids would be more common during the later stages of pregnancy.

Page: 294
6. A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating which of the following?
A) Iron-deficiency anemia
B) A multiple gestation pregnancy
C) Greater-than-expected weight gain
D) Hemodilution of pregnancy
Ans: D
Response:
During pregnancy, the red blood cell count increases along with an increase in plasma volume. However, there is a greater increase in the plasma volume as a result of hormonal factors and sodium and water retention. Thus, the plasma increase exceeds the increase in RBCs, resulting in hemodilution of pregnancy, which is also called physiologic anemia of pregnancy. Changes in maternal iron levels would be more indicative of an iron-deficiency anemia. Although anemia may be present with a multiple gestation, an ultrasound would be a more reliable method of identifying it. Weight gain does not correlate with hemoglobin levels.

Page: 298
7. The nurse is discussing the insulin needs of a primaparous client with diabetes who has been using insulin for the past few years. The nurse informs the client that her insulin needs will increase during pregnancy based on the nurse’s understanding that the placenta produces:
A) hCG, which increases maternal glucose levels
B) hPL, which deceases the effectiveness of insulin
C) Estriol, which interferes with insulin crossing the placenta
D) Relaxin, which decreases the amount of insulin produced
Ans: B
Response:
hPL acts as an antagonist to insulin, so the mother must produce more insulin to overcome this resistance. If the mother has diabetes, then her insulin need would most likely increase to meet this demand. hCG does not affect insulin and glucose level. Estrogen, not estriol, is believed to oppose insulin. In addition, insulin does not cross the placenta. Relaxin is not associated with insulin resistance.

Page: 298
8. When teaching a pregnant client about the physiologic changes of pregnancy, the nurse reviews the effect of pregnancy on glucose metabolism. Which of the following would the nurse include as the underlying reason for the effect?
A) Pancreatic function is affected by pregnancy.
B) Glucose is utilized more rapidly during a pregnancy.
C) The pregnant woman increases her dietary intake.
D) Glucose moves through the placenta to assist the fetus.
Ans: D
Response:
The growing fetus has large needs for glucose, amino acids, and lipids, placing demands on maternal glucose stores. During the first half of pregnancy, much of the maternal glucose is diverted to the growing fetus. The pancreas continues to function during pregnancy. However, the placental hormones can affect maternal insulin levels. The demand for glucose by the fetus during pregnancy is high, but it is not necessarily used more rapidly. Placental hormones, not the woman’s dietary intake, play a major role in glucose metabolism during pregnancy.

Page: 307
9. When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
A) Ambivalence
B) Introversion
C) Acceptance
D) Emotional lability
Ans: A
Response:
During the first trimester, the pregnant woman commonly experiences ambivalence, with conflicting feelings at the same time. Introversion heightens during the first and third trimesters when the woman’s focus is on behaviors that will ensure a safe and healthy pregnancy outcome. Acceptance usually occurs during the second trimester. Emotional lability (mood swings) is characteristic throughout a woman’s pregnancy.

Page: 308
10. The nurse is assessing a pregnant woman in the second trimester. Which of the following tasks would indicate to the nurse that the client is incorporating the maternal role into her personality?
A) The woman demonstrates concern for herself and her fetus as a unit.
B) The client identifies what she must give up to assume her new role.
C) The woman acknowledges the fetus as a separate entity within her.
D) The client demonstrates unconditional acceptance without rejection.
Ans: C
Response:
Incorporation of the maternal role into her personality indicates acceptance by the pregnant woman. In doing so, the woman becomes able to identify the fetus as a separate individual. Demonstrating concern for herself and her fetus as a unit is associated with introversion and more commonly occurs during the third trimester. Identification of what the mother must give up to assume the new role occurs during the first trimester. Demonstrating unconditional acceptance without rejection occurs during the third trimester.