Ricci Chapter 12 - Test Bank - 4th Edition || 100% Right
Solutions.
1. A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse
with my husband." The woman's pregnancy has been uneventful. The nurse responds based on
the understanding that:
A. it is safe to have intercourse at this time.
B. intercourse at this time is likely to cause rupture of membranes.
C. there are other ways that the couple can satisfy their needs.
D. intercourse at this time is likely to result in premature labor. Correct Answer: A
Rationale: Sexual activity is permissible during pregnancy unless there is a history of vaginal
bleeding, placenta previa, risk of preterm labor, multiple gestation, incompetent cervix,
premature rupture of membranes, or presence of infection. Rupture of membranes or premature
labor is unlikely since the woman's pregnancy has been uneventful so far. Alternative sexual
positions may be necessary as the woman's abdomen increases in size.
2. On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish
coloration of the cervix and vaginal mucosa. The nurse documents this finding as:
A. Hagar sign.
B. Goodall sign.
C. Chadwick sign.
D. Homans sign. Correct Answer: C
Rationale: Chadwick sign refers to the bluish coloration of the cervix and vaginal mucosa. Hegar
sign refers to softening of the isthmus. Goodell sign refers to softening of the cervix. Homans
sign indicates pain on dorsiflexion of the foot.
3. A nurse is teaching a pregnant couple about birth education. The nurse determines that the
teaching was successful when the couple makes which statement?
A. "We'll have the knowledge to ensure a pain-free birth."
B. "We'll know what to do to actively take part in our child's birth."
C. "We won't be anxious, so the birth will be uncomplicated."
D. "We will be in total control of the birth process." Correct Answer: B
Rationale: The primary focus of birth education is to provide information and support to clients
and their families to foster a more active role in the upcoming birth. Some methods of birth
education focus on pain-free childbirth. Information provided in birth education classes helps to
minimize anxiety and provide the couple with control over the situation, but elimination of
anxiety or total control is unrealistic.
4. When assessing a woman at follow-up prenatal visits, the nurse would anticipate which
procedure to be performed?
A. hemoglobin and hematocrit
B. urine for culture
C. fetal ultrasound
D. fundal height measurement Correct Answer: D
Rationale: On every follow-up visit, fundal height measurements are performed to evaluate fetal
growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be
, done on the initial visit and then repeated if the woman's status indicates a need for doing so.
Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are
signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal
period, but it is not done at every visit.
5. During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing
and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute
(increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral
crackles in the lower lung bases. Which nursing diagnosis would be the priority for this client?
A. Ineffective tissue perfusion related to supine hypotensive syndrome
B. Impaired gas exchange related to pulmonary congestion
C. Activity intolerance related to increased metabolic requirements
D. Anxiety related to fear of pregnancy outcome Correct Answer: B
Rationale: Typically, heart rate increases by approximately 10 to 15 beats per minute during
pregnancy and the lungs should be clear. Dyspnea may occur during the third trimester as the
enlarging uterus presses on the diaphragm. However, the findings described indicate that the
woman is experiencing impaired gas exchange. There is no evidence to support supine
hypotensive syndrome, increased metabolism, or anxiety.
6. When preparing a woman for an amniocentesis, the nurse would instruct her to perform which
action?
A. Shower with an antiseptic scrub.
B. Swallow the preprocedure sedative.
C. Empty the bladder.
D. Lie on the left side. Correct Answer: C
Rationale: Before an amniocentesis, the woman should empty her bladder to reduce the risk of
bladder puncture during the procedure. Showering with an antiseptic scrub and preprocedural
sedation are not necessary. The woman usually is positioned in a way that provides an adequate
pocket of amniotic fluid on ultrasound.
7. A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history
reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at
39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation.
Using the GTPAL method, the nurse would document her obstetric history as:
A. 3 2 1 0 3.
B. 3 1 2 2 3.
C. 4 1 1 1 3.
D. 4 2 1 3 1. Correct Answer: C
Rationale: Using the GTPAL method, the woman's history would be documented as 4 (her fourth
pregnancy), 1 (number of term pregnancies), 1 (number of pregnancies ending in preterm birth),
1 (number of pregnancies ending before 20 weeks or viability), and 3 (number of living
children).
8. A client's last menstrual period was April 11. Using the Naegele rule, her estimated date of
delivery (EDD) would be:
A. January 4.
Solutions.
1. A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse
with my husband." The woman's pregnancy has been uneventful. The nurse responds based on
the understanding that:
A. it is safe to have intercourse at this time.
B. intercourse at this time is likely to cause rupture of membranes.
C. there are other ways that the couple can satisfy their needs.
D. intercourse at this time is likely to result in premature labor. Correct Answer: A
Rationale: Sexual activity is permissible during pregnancy unless there is a history of vaginal
bleeding, placenta previa, risk of preterm labor, multiple gestation, incompetent cervix,
premature rupture of membranes, or presence of infection. Rupture of membranes or premature
labor is unlikely since the woman's pregnancy has been uneventful so far. Alternative sexual
positions may be necessary as the woman's abdomen increases in size.
2. On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish
coloration of the cervix and vaginal mucosa. The nurse documents this finding as:
A. Hagar sign.
B. Goodall sign.
C. Chadwick sign.
D. Homans sign. Correct Answer: C
Rationale: Chadwick sign refers to the bluish coloration of the cervix and vaginal mucosa. Hegar
sign refers to softening of the isthmus. Goodell sign refers to softening of the cervix. Homans
sign indicates pain on dorsiflexion of the foot.
3. A nurse is teaching a pregnant couple about birth education. The nurse determines that the
teaching was successful when the couple makes which statement?
A. "We'll have the knowledge to ensure a pain-free birth."
B. "We'll know what to do to actively take part in our child's birth."
C. "We won't be anxious, so the birth will be uncomplicated."
D. "We will be in total control of the birth process." Correct Answer: B
Rationale: The primary focus of birth education is to provide information and support to clients
and their families to foster a more active role in the upcoming birth. Some methods of birth
education focus on pain-free childbirth. Information provided in birth education classes helps to
minimize anxiety and provide the couple with control over the situation, but elimination of
anxiety or total control is unrealistic.
4. When assessing a woman at follow-up prenatal visits, the nurse would anticipate which
procedure to be performed?
A. hemoglobin and hematocrit
B. urine for culture
C. fetal ultrasound
D. fundal height measurement Correct Answer: D
Rationale: On every follow-up visit, fundal height measurements are performed to evaluate fetal
growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be
, done on the initial visit and then repeated if the woman's status indicates a need for doing so.
Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are
signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal
period, but it is not done at every visit.
5. During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing
and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute
(increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral
crackles in the lower lung bases. Which nursing diagnosis would be the priority for this client?
A. Ineffective tissue perfusion related to supine hypotensive syndrome
B. Impaired gas exchange related to pulmonary congestion
C. Activity intolerance related to increased metabolic requirements
D. Anxiety related to fear of pregnancy outcome Correct Answer: B
Rationale: Typically, heart rate increases by approximately 10 to 15 beats per minute during
pregnancy and the lungs should be clear. Dyspnea may occur during the third trimester as the
enlarging uterus presses on the diaphragm. However, the findings described indicate that the
woman is experiencing impaired gas exchange. There is no evidence to support supine
hypotensive syndrome, increased metabolism, or anxiety.
6. When preparing a woman for an amniocentesis, the nurse would instruct her to perform which
action?
A. Shower with an antiseptic scrub.
B. Swallow the preprocedure sedative.
C. Empty the bladder.
D. Lie on the left side. Correct Answer: C
Rationale: Before an amniocentesis, the woman should empty her bladder to reduce the risk of
bladder puncture during the procedure. Showering with an antiseptic scrub and preprocedural
sedation are not necessary. The woman usually is positioned in a way that provides an adequate
pocket of amniotic fluid on ultrasound.
7. A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history
reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at
39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation.
Using the GTPAL method, the nurse would document her obstetric history as:
A. 3 2 1 0 3.
B. 3 1 2 2 3.
C. 4 1 1 1 3.
D. 4 2 1 3 1. Correct Answer: C
Rationale: Using the GTPAL method, the woman's history would be documented as 4 (her fourth
pregnancy), 1 (number of term pregnancies), 1 (number of pregnancies ending in preterm birth),
1 (number of pregnancies ending before 20 weeks or viability), and 3 (number of living
children).
8. A client's last menstrual period was April 11. Using the Naegele rule, her estimated date of
delivery (EDD) would be:
A. January 4.
