Ricci Chapter 19 - Test Bank - 4th Edition || 100% Errorless
Answers.
1. After teaching a woman who has had an evacuation for gestational trophoblastic disease
(hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the
nurse's teaching was successful?
A. "I will be sure to avoid getting pregnant for at least 1 year."
B. "My intake of iron will have to be closely monitored for 6 months."
C. "My blood pressure will continue to be increased for about 6 more months."
D. "I won't use my birth control pills for at least a year or two." Correct Answer: A
Rationale: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is
necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial
hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year
because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not
important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable
contraceptive is strongly recommended so that pregnancy is avoided.
2. A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The
nurse determines that the medication is at a therapeutic level based on which finding?
A. urinary output of 20 mL per hour
B. respiratory rate of 10 breaths/minute
C. deep tendons reflexes 2+
D. difficulty in arousing Correct Answer: C
Rationale: With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and
therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of
less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium
toxicity.
3. Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the
client crying. Which response by the nurse would be most appropriate?
A. "Why are you crying?"
B. "Will a pill help your pain?"
C. "I'm sorry you lost your baby."
D. "A baby still wasn't formed in your uterus." Correct Answer: C
Rationale: Telling the client that the nurse is sorry for the loss acknowledges the loss to the
woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is
ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client
that the baby was not formed is inappropriate and discounts any feelings or beliefs that the client
has.
4. A nurse is reviewing a client's history and physical examination findings. Which information
would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
A. use of oral contraceptives for 5 years
B. ovarian cyst 2 years ago
C. recurrent pelvic infections
D. heavy, irregular menses Correct Answer: C
, Rationale: In the general population, most cases of ectopic pregnancy are the result of tubal
scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy,
irregular menses are not considered risk factors for ectopic pregnancy.
5. A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the
nurse identify as the priority?
A. hemorrhage
B. jaundice
C. edema
D. infection Correct Answer A
Rationale: With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage.
Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy.
6. It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help
prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at
which time?
A. at 32 weeks' gestation and immediately before discharge
B. 24 hours before birth and 24 hours after birth
C. in the first trimester and within 2 hours of birth
D. at 28 weeks' gestation and again within 72 hours after birth Correct Answer: D
Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at
28 weeks and again within 72 hours after birth.
7. A woman pregnant with twins comes to the clinic for an evaluation. While assessing the
client, the nurse would be especially alert for signs and symptoms for which potential problem?
A. oligohydramnios
B. preeclampsia
C. post-term labor
D. chorioamnionitis Correct Answer: B
Rationale: Women with multiple gestations are at high risk for preeclampsia, preterm labor,
polyhydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no
association between multiple gestations and the development of chorioamnionitis.
8. A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After
reviewing a client's history, which factor would the nurse identify as placing her at risk for
preeclampsia?
A. Her mother had preeclampsia during pregnancy.
B. Client has a twin sister.
C. Her sister-in-law had gestational hypertension.
D. This is the client's second pregnancy. Correct Answer: A
Rationale: A family history of preeclampsia, such as a mother or sister, is considered a risk factor
for the client. Having a twin sister or having a sister-in-law with gestational hypertension would
not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy,
then she would be at risk in her second pregnancy.
9. A client with hyperemesis gravidarum is admitted to the facility after being cared for at home
Answers.
1. After teaching a woman who has had an evacuation for gestational trophoblastic disease
(hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the
nurse's teaching was successful?
A. "I will be sure to avoid getting pregnant for at least 1 year."
B. "My intake of iron will have to be closely monitored for 6 months."
C. "My blood pressure will continue to be increased for about 6 more months."
D. "I won't use my birth control pills for at least a year or two." Correct Answer: A
Rationale: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is
necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial
hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year
because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not
important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable
contraceptive is strongly recommended so that pregnancy is avoided.
2. A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The
nurse determines that the medication is at a therapeutic level based on which finding?
A. urinary output of 20 mL per hour
B. respiratory rate of 10 breaths/minute
C. deep tendons reflexes 2+
D. difficulty in arousing Correct Answer: C
Rationale: With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and
therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of
less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium
toxicity.
3. Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the
client crying. Which response by the nurse would be most appropriate?
A. "Why are you crying?"
B. "Will a pill help your pain?"
C. "I'm sorry you lost your baby."
D. "A baby still wasn't formed in your uterus." Correct Answer: C
Rationale: Telling the client that the nurse is sorry for the loss acknowledges the loss to the
woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is
ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client
that the baby was not formed is inappropriate and discounts any feelings or beliefs that the client
has.
4. A nurse is reviewing a client's history and physical examination findings. Which information
would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
A. use of oral contraceptives for 5 years
B. ovarian cyst 2 years ago
C. recurrent pelvic infections
D. heavy, irregular menses Correct Answer: C
, Rationale: In the general population, most cases of ectopic pregnancy are the result of tubal
scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy,
irregular menses are not considered risk factors for ectopic pregnancy.
5. A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the
nurse identify as the priority?
A. hemorrhage
B. jaundice
C. edema
D. infection Correct Answer A
Rationale: With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage.
Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy.
6. It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help
prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at
which time?
A. at 32 weeks' gestation and immediately before discharge
B. 24 hours before birth and 24 hours after birth
C. in the first trimester and within 2 hours of birth
D. at 28 weeks' gestation and again within 72 hours after birth Correct Answer: D
Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at
28 weeks and again within 72 hours after birth.
7. A woman pregnant with twins comes to the clinic for an evaluation. While assessing the
client, the nurse would be especially alert for signs and symptoms for which potential problem?
A. oligohydramnios
B. preeclampsia
C. post-term labor
D. chorioamnionitis Correct Answer: B
Rationale: Women with multiple gestations are at high risk for preeclampsia, preterm labor,
polyhydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no
association between multiple gestations and the development of chorioamnionitis.
8. A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After
reviewing a client's history, which factor would the nurse identify as placing her at risk for
preeclampsia?
A. Her mother had preeclampsia during pregnancy.
B. Client has a twin sister.
C. Her sister-in-law had gestational hypertension.
D. This is the client's second pregnancy. Correct Answer: A
Rationale: A family history of preeclampsia, such as a mother or sister, is considered a risk factor
for the client. Having a twin sister or having a sister-in-law with gestational hypertension would
not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy,
then she would be at risk in her second pregnancy.
9. A client with hyperemesis gravidarum is admitted to the facility after being cared for at home
