Silvestri Chapter 21 Ed#551

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 018 (edited file)—"Obstetrical Assessment" 10/14/08, Page 1 of 6, 0 Figure(s), 0 Table(s), 3 Box(es)

21: Obstetrical Assessment PRACTICE QUESTIONS 1. A client arrives at the prenatal clinic for the first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was September 19, 2007. Using Nägele’s rule, the nurse determines the estimated date of confinement as: 1. July 26, 2008 2. June 12, 2008 3. June 26, 2008 4. July 12, 2008 Answer: 3 Rationale: Accurate use of Nägele’s rule requires that the woman have a regular 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period (LMP), subtract 3 months, and then add 1 year to that date. First day of the LMP: September 19, 2007; add 7 days: September 26, 2007; subtract 3 months: June 26, 2007; add 1 year: June 26, 2008. Test-Taking Strategy: Knowledge regarding the use of Nägele’s rule is required to answer this question. Read all of the options carefully, noting the dates and years in the options, before selecting an answer. Review Nägele’s rule if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 34. 2.  A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as: 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 0, P = 1, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1 Answer: 2 Rationale: Pregnancy outcomes can be described with the GTPAL acronym: G=gravidity = number of pregnancies; T=term births = number born at term (40 weeks); P=preterm births = number born before 40 weeks’ gestation; A=abortions/miscarriages = number of abortions/miscarriages (included in gravida if before 20 weeks’ gestation; included in para if past 20 weeks’ gestation); L=live births = number of live births or living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 1 and number of term births is 0. The number of abortions is 0 and number of live births is 1. Test-Taking Strategy: Knowledge and understanding of the GTPAL acronym will direct you to option 2. If you had difficulty answering this question, review this method of describing pregnancy outcomes.

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Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Wong, D., Perry, S., & Hockenberry, M. (2002). Maternal child nursing care (2nd). St. Louis: Mosby, p. 168. 3. A nurse is collecting data during an admission assessment on a client who is pregnant with twins. The client also has a 5-year-old child. The nurse would document which gravida and para status on this client? 1. Gravida III, para II 2. Gravida II, para II 3. Gravida I, para I 4. Gravida II, para I Answer: 4 Rationale: Gravida is a term that refers to a woman who is or has been pregnant, regardless of the duration of the pregnancy. Para is a term that means the number of pregnancies that have progressed past 20 weeks’ gestation. Parity does not reflect the number of fetuses or infants. Option 1, 2, and 3 are incorrect based on the above definition. Test-Taking Strategy: Knowledge of the terms gravida and para is necessary to answer this question correctly. Review the description of these terms if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 3334. 4. A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding necessitating further testing? 1. Consistent increase in fundal height 2. Fetal heart rate of 180 beats per minute 3. Braxton Hicks contractions 4. Quickening Answer: 2 Rationale: The fetal heart rate depends on gestational age. It is 160 to 170 beats per minute in the first trimester and slows with fetal growth to approximately 110 or 120 to 160 beats per minute. Options 1, 3, and 4 are normal expected findings. Test-Taking Strategy: Use the process of elimination. Note the key words, indicates an abnormal physical finding. Recalling the normal fetal heart rate will direct you to option 2. Review normal assessment findings in pregnancy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 78.

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5. A nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. The nurse tells the client that: 1. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. 2. Total abstinence from sexual intercourse is necessary during the entire pregnancy. 3. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor. Answer: 4 Rationale: For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy and should be used only when a life-threatening infection is present. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, they should continue to abstain until they become culture-negative, because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry will promote healing. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because of the absolute word “entire” in these options. From the remaining options, recalling that the lesions should be kept clean and dry to promote healing will assist in eliminating option 3. If you had difficulty with this question, review the content related to genital herpes as a maternal risk factor. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 338. 6. A nurse is collecting data on a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following? 1. 22 cm 2. 28 cm 3. 36 cm 4. 40 cm Answer: 2 Rationale: During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus’ age in weeks plus or minus 2 cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus and, at 36 weeks, the fundus is at the xiphoid process. Test-Taking Strategy: Use the process of elimination. Remember that during the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus’ age in weeks plus or minus 2 cm. If you are unfamiliar with this data collection technique, review this content area. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 192.

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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 425. 7. A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? 1. Instruct the client to maintain bed rest for the remainder of the pregnancy. 2. Instruct the client that these are common and may occur throughout the pregnancy. 3. Contact the physician. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition. Answer: 2 Rationale: Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 3, and 4 are unnecessary and inappropriate actions. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 are similar and can be eliminated first. From the remaining options, knowing that Braxton Hicks contractions are common and can occur throughout pregnancy will assist in directing you to option 2. If you had difficulty with this question, review the physiology associated with Braxton Hicks contractions. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 83. 8. A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell’s sign. The nurse determines that this sign is indicative of: 1. A softening of the cervix 2. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. The presence of fetal movement Answer: 1 Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell’s sign. Cervical softening is noted by the examiner during pelvic examination. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta. hCG is noted in maternal urine in a positive urine pregnancy test. Goodell’s sign does not indicate the presence of fetal movement. Test-Taking Strategy: Use the process of elimination and knowledge regarding the physiological findings in Goodell’s sign to answer this question. Remember that Goodell’s sign refers to a softening of the cervix. If you had difficulty with this question, review the changes in the cervix that occurs during pregnancy. Level of Cognitive Ability: Comprehension

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Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 264. 9. A nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term? 1. “It is the irregular, painless contractions that occur throughout pregnancy.” 2. “It is the soft blowing sound that can be heard when the uterus is auscultated.” 3. “It is the fetal movement that is felt by the mother.” 4. “It is the thinning of the lower uterine segment.” Answer: 3 Rationale: Quickening is fetal movement and may occur as early as the 14th to 16th weeks of gestation, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, which is known as uterine souffle. This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar’s sign. Test-Taking Strategy: Use the process of elimination and knowledge regarding the term quickening to answer this question. Remember that quickening is fetal movement. If you are unfamiliar with this sign associated with pregnancy, review this content area. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 386. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 163. 10. A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between: 1. 6 to 8 weeks of gestation 2. 8 to 10 weeks of gestation 3. 10 to 12 weeks of gestation 4. 14 to 16 weeks of gestation Answer: 4 Rationale: Quickening is fetal movement and may occur as early as the 14th to 16th weeks of gestation. The expectant mother first notices subtle fetal movements during this time, which gradually increase in intensity. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination and knowledge regarding the occurrence of quickening. In this situation, it is best to select the option that indicates the greatest length of gestational time. Review the process of quickening if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance

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Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 147. 11. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. ____Uterine enlargement ____Fetal heart rate detected by a nonelectronic device ____Outline of fetus via radiography or ultrasound ____Chadwick's sign ____Braxton Hicks contractions ____Ballottement Answers: Uterine enlargement Chadwick's sign Braxton Hicks contractions Ballottement Rationale: The probable signs of pregnancy include uterine enlargement, Hegar's sign (softening and thinning of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs about week 6), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test measuring for human chorionic gonadotropin (hCG). Positive signs of pregnancy include fetal heart rate detected by an electronic device (Doppler transducer) at 8 to 12 weeks and by a nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus via radiography or ultrasound. Test-Taking Strategy: Focusing on the issue, probable signs of pregnancy, will assist in answering this question. Remember that detection of the fetal heart rate and an outline of the fetus via radiography or ultrasound are positive signs of pregnancy. Review the probable signs of pregnancy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 132.