NUR 311 - EXAM 2 QUESTIONS WITH COMPLETE
SOLUTIONS
A 22-year-old woman pregnant with a single fetus has a
preconception body mass index (BMI) of 24. When she was
seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg
(4 lbs) since conception. How would the nurse interpret this?
A. This weight gain indicates possible gestational hypertension.
B. This weight gain indicates that the woman's infant is at risk
for intrauterine growth restriction (IUGR).
C. This weight gain cannot be evaluated until the woman has
been observed for several more weeks.
D. The woman's weight gain is appropriate for this stage of
pregnancy. Correct Answer •D
Although this is an accurate statement, it does not apply to this
client. The desirable weight gain during pregnancy varies among
women. The primary factor to consider in making a weight gain
recommendation is the appropriateness of the prepregnancy
weight for the woman's height. A commonly used method of
evaluating the appropriateness of weight for height is the BMI.
This woman has gained the appropriate amount of weight for her
size at this point in her pregnancy. C. Weight gain should take
place throughout the pregnancy. The optimal rate of weight gain
depends on the stage of the pregnancy. This is an accurate
statement. This woman's BMI is within the normal range.
During the first trimester, the average total weight gain is only 1
to 2.5 kg
,A client decides not to use hormone therapy after menopause.
What is the best instruction the nurse should provide to this
client to decrease the serious effects of menopause?
a.Take 800 mg of calcium every day.
b.Supplement the diet with vitamin E.
c.Maintain a high-protein, low-fat diet.
d.Engage in aerobic, weight-bearing exercise. Correct Answer
•Answer: D
•Rationale: Menopause and decreased estrogen levels increase
the risk for osteoporosis (secondary to bone density loss). A
regular moderate program (3 to 4 times per week) of aerobic and
weight-bearing exercises can slow the process of bone loss and a
tendency toward weight gain.
A first-time father is concerned that his 3-day-old daughter's
skin looks "yellow." In the nurse's explanation of physiologic
jaundice, which point should be included?
a. Physiologic jaundice occurs during the first 24 hours of life.
b. Physiologic jaundice is caused by blood incompatibilities
between the mother and infant blood types.
c. The bilirubin levels of physiologic jaundice peak at 5 to 7
mg/dL between the second and fourth days of life.
d. This condition is also known as breast milk jaundice. Correct
Answer §ANS: C
§Physiologic jaundice becomes visible when the serum bilirubin
reaches 5 to 7 mg/dL, which occurs when the baby is
approximately 3 days old. This finding is within normal limits
for the newborn. Pathologic jaundice occurs during the first 24
hours of life. Pathologic jaundice is caused by blood
incompatibilities, causing excessive destruction of erythrocytes,
,and must be investigated. Breast milk jaundice occurs in one
third of breastfed infants at 2 weeks and is caused by an
insufficient intake of fluids.
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. Correct
Answer 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.
A laboring woman's amniotic membranes have just ruptured.
The immediate action of the nurse would be to:
A. assess the fetal heart rate (FHR) pattern.
B. perform a vaginal examination.
C. inspect the characteristics of the fluid.
D. assess maternal temperature. Correct Answer A
, • The first nursing action after the membranes are ruptured is to
check the FHR. Compression of the cord could occur after
rupture leading to fetal hypoxia as reflected in an alteration in
FHR pattern, characteristically variable decelerations. The same
initial action should follow artificial rupture of the membranes
(amniotomy). These are all important and should be done after
the FHR and pattern are assessed. These are all important and
should be done after the FHR and pattern are assessed. These are
all important and should be done after the FHR and pattern are
assessed.
A maternal serum alpha-fetoprotein (MSAFP) test is performed
at 16 to 18 weeks of gestation. An elevated level has been
associated with:
A. Down syndrome.
B. sickle cell anemia.
C. cardiac defects.
D. open neural tube defects such as spina bifida. Correct
Answer •D
•Low levels of MSAFP are associated with Down syndrome.
Sickle cell anemia is not detected by the MSAFP. Cardiac
defects would not be detected with the MSAFP. A triple marker
test determines the levels of MSAFP along with serum levels of
estriol and human chorionic gonadotropin; an elevated level is
associated with open neural tube defects.
A nurse teaches a pregnant woman about the presumptive,
probable, and positive signs of pregnancy. The woman
demonstrates an understanding of the nurse's instructions if she
states that a positive sign of pregnancy is:
SOLUTIONS
A 22-year-old woman pregnant with a single fetus has a
preconception body mass index (BMI) of 24. When she was
seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg
(4 lbs) since conception. How would the nurse interpret this?
A. This weight gain indicates possible gestational hypertension.
B. This weight gain indicates that the woman's infant is at risk
for intrauterine growth restriction (IUGR).
C. This weight gain cannot be evaluated until the woman has
been observed for several more weeks.
D. The woman's weight gain is appropriate for this stage of
pregnancy. Correct Answer •D
Although this is an accurate statement, it does not apply to this
client. The desirable weight gain during pregnancy varies among
women. The primary factor to consider in making a weight gain
recommendation is the appropriateness of the prepregnancy
weight for the woman's height. A commonly used method of
evaluating the appropriateness of weight for height is the BMI.
This woman has gained the appropriate amount of weight for her
size at this point in her pregnancy. C. Weight gain should take
place throughout the pregnancy. The optimal rate of weight gain
depends on the stage of the pregnancy. This is an accurate
statement. This woman's BMI is within the normal range.
During the first trimester, the average total weight gain is only 1
to 2.5 kg
,A client decides not to use hormone therapy after menopause.
What is the best instruction the nurse should provide to this
client to decrease the serious effects of menopause?
a.Take 800 mg of calcium every day.
b.Supplement the diet with vitamin E.
c.Maintain a high-protein, low-fat diet.
d.Engage in aerobic, weight-bearing exercise. Correct Answer
•Answer: D
•Rationale: Menopause and decreased estrogen levels increase
the risk for osteoporosis (secondary to bone density loss). A
regular moderate program (3 to 4 times per week) of aerobic and
weight-bearing exercises can slow the process of bone loss and a
tendency toward weight gain.
A first-time father is concerned that his 3-day-old daughter's
skin looks "yellow." In the nurse's explanation of physiologic
jaundice, which point should be included?
a. Physiologic jaundice occurs during the first 24 hours of life.
b. Physiologic jaundice is caused by blood incompatibilities
between the mother and infant blood types.
c. The bilirubin levels of physiologic jaundice peak at 5 to 7
mg/dL between the second and fourth days of life.
d. This condition is also known as breast milk jaundice. Correct
Answer §ANS: C
§Physiologic jaundice becomes visible when the serum bilirubin
reaches 5 to 7 mg/dL, which occurs when the baby is
approximately 3 days old. This finding is within normal limits
for the newborn. Pathologic jaundice occurs during the first 24
hours of life. Pathologic jaundice is caused by blood
incompatibilities, causing excessive destruction of erythrocytes,
,and must be investigated. Breast milk jaundice occurs in one
third of breastfed infants at 2 weeks and is caused by an
insufficient intake of fluids.
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. Correct
Answer 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.
A laboring woman's amniotic membranes have just ruptured.
The immediate action of the nurse would be to:
A. assess the fetal heart rate (FHR) pattern.
B. perform a vaginal examination.
C. inspect the characteristics of the fluid.
D. assess maternal temperature. Correct Answer A
, • The first nursing action after the membranes are ruptured is to
check the FHR. Compression of the cord could occur after
rupture leading to fetal hypoxia as reflected in an alteration in
FHR pattern, characteristically variable decelerations. The same
initial action should follow artificial rupture of the membranes
(amniotomy). These are all important and should be done after
the FHR and pattern are assessed. These are all important and
should be done after the FHR and pattern are assessed. These are
all important and should be done after the FHR and pattern are
assessed.
A maternal serum alpha-fetoprotein (MSAFP) test is performed
at 16 to 18 weeks of gestation. An elevated level has been
associated with:
A. Down syndrome.
B. sickle cell anemia.
C. cardiac defects.
D. open neural tube defects such as spina bifida. Correct
Answer •D
•Low levels of MSAFP are associated with Down syndrome.
Sickle cell anemia is not detected by the MSAFP. Cardiac
defects would not be detected with the MSAFP. A triple marker
test determines the levels of MSAFP along with serum levels of
estriol and human chorionic gonadotropin; an elevated level is
associated with open neural tube defects.
A nurse teaches a pregnant woman about the presumptive,
probable, and positive signs of pregnancy. The woman
demonstrates an understanding of the nurse's instructions if she
states that a positive sign of pregnancy is:
