MCH Module 1 – 3 Learning Activity 1

Name: CRN:
Answer the following questions. (Consider working with a partner or two or three.)
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Chapter 1: Foundations of Maternity, Women's Health, and Child Health Nursing

[1] Match the term with the correct definition.

B Advocacy person's rights
E Morbidity c) Negligence of a professional person
C Malpractice d) Provide maternity care outside acute-care
A Neonatal mortality settings for low-risk pregnant women
D Birth centers e) Ratio of sick-to-well persons in a defined
G Ethics population
F Bioethics f) Application of ethics to health care
H Negligence g) Rules or principles that govern conduct
a) Infant deaths that occur in the first 28 days h) Failure to act in the way a reasonable,
of life prudent person of a similar background
b) Speaking or arguing in support of a policy or would act in a similar circumstance

HISTORICAL PERSPECTIVES
Maternity Nursing
[2] Identify the three basic principles of family-centered maternity care.
a. Childbirth is usually a normal, healthy event in the life of a family.
b. Childbirth affects the entire family, and family restructuring is required.
c. Families can make decisions about care, provided they are given adequate information
and professional support.

[3] Describe each of these settings for childbirth.

a) The traditional hospital setting: labor, birth, recovery, and postpartum care occur in separate
rooms; delay of parent–infant contact.
b) Labor, delivery, and recovery (LOR) rooms: labor, birth, and immediate recovery occur in a single
room, with transfer to a postpartum room for continuing care; emphasis on keeping parents and
infants together; liberal visiting.
c) Labor, delivery, recovery, and postpartum (LDRP) rooms: same as LDR rooms except that the
mother and infant remain in the same room where the birth occurred.
d) Birth centers: freestanding centers that provide antepartum, intrapartum, postpartum, and
newborn care to low-risk mothers and babies, normally staffed with certified nurse-midwives.
e) Home births: take place in a familiar setting with support people the mother wants, fewer nurse-
midwives now attend these births because malpractice insurance is expensive and difficult to
obtain

Pediatric Nursing
[4] Answer as either true (T}or false (F)
a) F Throughout history, children have been valued and protected by society.
b) T During the 19th century, the most serious child health problems were directly related to
poverty and overcrowding.
c) T The first public health program for mothers and children was initiated by Lillian Wald.
d) T Hospital policies have changed in response to an awareness of children's emotional and
psychological needs.
CURRENT TRENDS IN MATERNITY AND PEDIATRIC CARE
[5] How has cost containment affected maternity and pediatric care?
Prospective payment plans have had major effects on maternal and infant care, primarily with
respect to the length of stay. Mothers are typically discharged from the hospital at 48 hours after
normal vaginal birth and 96 hours after cesarean birth, unless the woman and her healthcare provider
choose an earlier discharge time.

[6] Answer as either true (T) or false (F)

a) F Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
provides supplemental food supplies to bottle-fed children but not to breastfeeding mothers.
b) T Premature births have increased in the past two decades.
c) F African-American women have lower maternal mortality rates than Caucasian women.
d) T Infant mortality rates have continued to drop since 1950 as a result of better neonatal
care.
e) T Unintentional injuries are the leading cause of death in children aged 1 to 19 years.
f) F There is no link between children living in poverty and poorer health outcomes.

ETHICAL PERSPECTIVES ON MATERNAL AND CHILD NURSING

[7] Four of the most important ethical principles are beneficence, nonmaleficence, autonomy, and justice

[8] What are the four elements of negligence/malpractice?

1. Duty
2. Breach of duty
3. Damage
4. Proximate cause

[9] Identify the four requirements of informed consent.

1. Patient’s competence to consent
2. Full disclosure of information
3. Patient’s understanding of information
4. Patient’s voluntary consent

CLINICAL JUDGMENT
[10] The nurse is caring for a 23-year-old client who is 24 weeks pregnant with her first child. The
client reports that she is using illegal drugs on a weekly basis during her pregnancy. What are the
nurse's legal and ethical responsibilities to the client and her unborn baby in this situation? Select all
that apply.
a) Report the client to law enforcement when her appointment is over.
b) Counsel the client about the effect of illegal drugs on the fetus.
c) Assess for family support.
d) Ask the client more about her behaviors.
e) Provide information about community resources that are available to the client.
f) Determine if the client's insurance will pay for a substance use treatment program.
Answer: B, C, D, E
Rationale: Patient teaching is necessary so the mother can be aware of the effect the drugs will have
on the fetus if she wish to stop using while pregnant, it is important for a mother to be surrounded
with support and love especially since she is a younger patient with her first child, besides
establishing a rapport with the patient, assessment is one of the first step in nursing care.
[11] What was identified in the chapter as a societal issue that affects maternity and pediatric nursing?
a) Fewer children are living in poverty.
b) Violence in schools has decreased.
c) Families are the fastest growing group of homeless people.
d) The number of uninsured American children has decreased

[12] A practice model that uses a systematic approach to identify specific patients and manage patient
care is:
a) case management.
b) the nursing process.
c) a clinical pathway.
d) a health maintenance organization.

[13] Which statement about family-centered maternity care is correct?

a) Family-centered care decreases the responsibility of maternity nurses.
b) Although the settings have changed, childbirth is still viewed as a medical event.
c) Care is adapted to meet the physical and psychological needs of the family.
d) Maternal-infant bonding is the primary focus of family-centered care.

Chapter 2: The Nurse's Role in Maternity, Women's Health and Pediatric Nursing

THE ROLE OF THE PROFESSIONAL NURSE

[14] Answer as either true (T) or false (F).
a) T The professional nurse has a responsibility to provide high-quality care to all patients.
b) T Standards of practice describe the level of performance expected of a professional
nurse.
c) F Women's health nurse practitioners usually assist with childbirth.

[15] List six roles of maternity and pediatric nurses.

1. Care provider
2. Teacher
3. Collaborator
4. Researcher
5. Advocate
6. Manager

IMPLICATIONS OF CHANGING ROLES FOR NURSES

[16] How does therapeutic communication differ from social communication?
Therapeutic communication, unlike social communication, is purposeful, goal directed,
and focused. Although it may seem simple, therapeutic communication requires conscious effort
and considerable practice.

[17] When using active listening, the nurse attends to what is being said and nonverbal cues.

[18] In the following situations, identify the communication block illustrated by the nurse's response.
Provide an alternative nursing response.
a) A child is crying and resisting as the nurse is about to administer an intramuscular injection. The
nurse says, "This will not hurt a bit. You will be just fine."
 Communication block: failing to acknowledge the child’s feelings and providing false
reassurance.
Alternative response: You will feel a prick when I give you the needle. It’s okay to cry or yell if
you want to. Think you can keep your leg still for me? I will put a Band-Aid on it when I am
done.

b) A pregnant woman, on strict bed rest, tells the nurse , "I do not think I can stand much more of
this. I did not think my pregnancy would be like this." The nurse responds, "Rest up now. You
will not get this much rest again in your life."
Communication block: : failure to acknowledge the woman’s comments or feelings
Alternative response: This pregnancy has not gone as you expected. Let’s talk about how being
on bed rest has been difficult for you.

[19] The primary purpose of critical thinking in nursing is:

Help nurses make the best clinical judgements by identifying and overcoming habits that interfere
with decision making

[20] Identify the five steps of the critical thinking process .

1. Recognize assumptions.
2. Examine personal biases.
3. Analyze the need for closure.
4. Collect and analyze data.
5. Evaluate other factors that can impede critical thinking.

[21] Answer as either true (T) or false (F).

a) F A body posture that facilitates nurse-patient communication is talking with the arms
crossed over the chest.
b) F Cultural differences do not affect communication.
c) T Nonverbal behaviors may communicate a more powerful message to a patient than
spoken words.

THE NURSING PROCESS IN MATERNITY AND PEDIATRIC CARE

[22] For each broad goal, write at least three outcome criteria that are patient focused, use measurable
verbs, have a time frame, and are realistic.
a) Following a cesarean birth, the woman will have increased mobility.
o Patient will ambulate in her room by 24 hours after surgery. She will ambulate the
length of the hallway and back by 48 hours after surgery.
b) The pregnant woman will have adequate nutrition .
o Patient will bring a diet journal for 1 day that demonstrates the correct number of
servings from every food group by her next visit
c) The child with leukemia will not get an infection
o Patient will be free of signs of infection, as evidenced by absence of fever, no redness,
and negative lab cultures until his next examination within 2 weeks.

CLINICAL JUDGMENT
[23] A nurse is completing an admission assessment of a 32-year-old client who is 28 weeks pregnant.
The nurse understands the importance of communicating effectively using techniques with the client.
The nurse can identify behaviors that block communication. Select all that apply that would indicate
blocking behaviors.
a) Leaning toward the patient and stating, “tell me more about that.”
 b) Sitting with arms crossed, stating “do you know why you are being admitted?”
c) Stating “I just know everything is going to be OK for you and your baby.”
d) Stating “my baby was born early and he had a rough start but is doing great now.”
e) Stating “I sense that you are concerned about what to expect in the hospital. I will explain
everything we are going to do and make sure your questions are answered.”
f) Stating “If I were in your position, I would have insisted that I wait to come to the hospital.”
g) Stating “ what is most important to you regarding your care today?”
Answer: B, C, D, F
Rationale: the nurse is portraying nontherapeutic communication by crossing her arms, giving false
reassurance, sharing personal stories and opinion

[24] Your friend says she is not sure she wants a doctor to deliver her second baby because she
believes doctors are too busy to talk with her when she has check ups. The best alternative
professional for you to suggest 1s the:
a) maternity nurse practitioner.
b) certified nurse-midwife.
c) lay midwife.
d) clinical nurse specialist.

[25] A primary difference between social and therapeutic communications is that therapeutic
communication is:
a) designed to obtain information in a minimum amount of time.
b) the only appropriate professional communication.
c) focused on achieving a relevant goal for the patient.
d) limited to the information necessary for safe care.

[26] A pregnant woman tells the nurse, "I am so confused. My husband wants me to have my tubes
tied after the baby comes, but what if something happens to the baby?" The nurse replies, "You are
afraid of having permanent contraception before you know if your baby is well." The nurse's response
is an example of:
a) directing.
b) paraphrasing.
c) summarizing.
d) pinpointing.

[27] A nursing diagnosis differs from a collaborative problem primarily regarding whether the nurse:
a) can prescribe definitive treatment for the problem.
b) identifies a patient's strength or weakness.
c) determines that an actual or a potential problem exists.
d) can evaluate the patient's response to treatment.

Chapter 5: Health Promotion for the Developing Child

[28] Match the term with the correct KEY TERM with its definition.
D Cephalocaudal c) Transmission of genetic characteristics
G Chronologic age d) Progression from head to toe
B Developmental age e) Loss of a milestone which had been obtained
H Growth spurts at an earlier age
C Heredity f) Behavior changes that occur as a result of
F Learning maturation and experience with the
I Nutrients environment
A Proximodistal g) Age in years
J Recommended dietary allowance h) Brief periods of a rapid increase in growth rate
E Regression i) Foods that supply the body with elements
necessary for metabolism
j) Recommendations for the average amount of
a) Progression from midline to periphery nutrients that should be consumed by healthy
b) Age based on functional behavior and ability people in the United States
to adapt to the environment

[29] Match each type of play with its description.

C Dramatic play represent an issue or a concern to be addressed
B Familiarization play b) Children use materials associated with health
A Symbolic play care in creative, playful activities
c) Children act out roles and experiences that
a) Children use games and interactions that happened to them or someone else

OVERVIEW OF GROWTH AND DEVELOPMENT

[30] Nurses need to have an understanding of growth and development to design care plans that: meet
the needs of their young patients

[31] An increase in physical size is referred to as: growth

[32] Physical changes in the complexity of body structures that enable a higher-level functioning are
known as: maturation

[33] Development is an increase in the capabilities resulting from a combination of growth,

maturation, and learning.

[34] Changes in behavior that occur as the result of both maturation and experience with the
environment are termed: learning

[35] Nurses must be familiar with normal patterns of growth and development so that delays can be
detected and treated early.

[36] Next to each age, write the anticipated corresponding stage of growth and development.
a) 3 weeks: newborn
b) 10 months: infancy
c) 2 years: toddlerhood
d) 4 years: preschool age
e) 8 years: school age
f) 17 years: adolescence

[37] List three parameters used to measure and assess growth in infants and children.
 weight, length (or height), and head circumference

[38] An infant's birth weight typically doubles by 6 months of age and triples by 1 year of age .

[39] Head circumference is an indicator of brain growth.

[40] Primary dentition consists of 20 teeth. Permanent teeth number 32 .

[41] Match each pattern of growth and development with its example.
D Cephalocaudal b) A toddler can use two-word sentences; a
A General to specific preschooler can tell stories.
C Proximodistal c) In the embryo, the development of the
B Simple to complex bronchus precedes the development of the
bronchioles and alveoli.
a) An infant responds to an earache by flailing d) The infant can lift the head before being able
the extremities; the toddler responds by to lift the trunk.
tugging at the ear.

Define critical period as it relates to childhood development: critical periods are blocks of time during
which children are ready to master specific developmental tasks.

[42] Answer as either true (T) or false (F).

a) T Toys manufactured outside of the United States may have high concentrations of lead.
b) T Maternal diabetes can adversely affect fetal development.
c) F Children are less susceptible to air pollution than adults because they have a smaller
lung capacity.
d) T Breastfeeding can expose infants to environmental toxins.
e) F A standard growth curve is appropriate for assessing all children regardless of their racial
or ethnic backgrounds.
f) T A child's temperament can influence how the parents interact with the child.
g) F Only inherited diseases can affect the growth and development in the fetus.

THEORIES OF GROWTH AND DEVELOPMENT

[43] Match each stage of Piaget's theory with the example that is characteristic of that stage.
C Sensorimotor a) Is able to see another's point of view
B Preoperational b) Exhibits magical thinking
A Concrete operations c) Develops a sense of object permanence
D Formal operations d) Is able to appreciate symbolism

[44] Identify which of Freud's stages of psychosexual development is represented by each of the
following:
a) Child explores the world with the mouth: Oral
b) Child may initially demonstrate aggression toward the same-sex parent: Phallic
c) Child develops an adult view of sexuality: Genital
d) Child learns to control the elimination processes: Anal
e) Child typically prefers same-sex friends: Latency

[45] Fill in the blanks in the following statements to complete the developmental tasks of Erikson
through adolescence.
a) Trust versus mistrust
b) Autonomy versus shame and doubt
 c) Initiative versus guilt
d) Industry versus inferiority
e) Identity versus role confusion

[46] Match each level of Kohlberg's theory with its example.

B Pre-morality b) "I won't hit them because the nurse will yell
A Morality of conventional role conformity at me."
C Morality of self-accepted moral principles c) "I won't blast my radio. It's not fair to the
a) "I'll take my medicine to make my nurse other patients".
happy".

THEORIES OF LANGUAGE DEVELOPMENT

[47] Language development closely parallels cognitive development.

[48] Receptive language is the ability to: understand the spoken word

[49] Expressive language is the ability to: produce meaningful vocalization

ASSESSMENT OF GROWTH
[50] Why are a child's height, weight, and head circumference plotted on standardized growth charts at
every well-child checkup? Physical growth in infants and young children is an indicator of physical
health.

[51] Body mass index measures growth and nutritional status in children older than 2 years.

[52] Why is it important to recognize abnormal growth patterns? The earlier growth disorders are
detected and treated, the better are the long-term prognoses.

ASSESSMENT OF DEVELOPMENT
[53] List four methods of assessing development:
o observe a child’s behavior and interactions
o interviewing a child and his or her parents
o physical examinations
o standardized assessment tools

[54] Name two prescreening tools that have been found to be sensitive and specific for detecting
developmental problems.
1. Ages and Stages Questionnaire
2. Parents’ Evaluation of Developmental Status (PEDS)

[55] The Denver Developmental Screening Test II (DDST-11) assesses development in which four
functional areas?
1. Gross motor
2. Fine motor
 3. Language
4. Personal - Social

[56] What is anticipatory guidance?

Basic information about normal growth and development as a child approaches different ages.

THE DEVELOPMENTAL ASSESSMENT

[57] Answer as either true (T) or false (F).
a) F Children's developmental needs are the same as their psychosocial needs.
b) T When discussing a child's development with parents, considering the family's culture is
important.
c) T Observing a child in various situations can provide information about the child's
development.

[58] Play is considered to be children's work.

[59] Practice play is also known as functional play.

[60] Symbolic play uses games and interactions to represent an issue to be addressed.

[61] Games include rules.

[62] Match each type of play with its description.

E Associative b) Child watches others playing
C Cooperative c) Children play in groups and establish rules for
B Onlooker participating
D Parallel d) Children play side-by-side but do not interact
A Solitary with each other
e) Children play together but without establishing
a) Child plays alone rules and goals

HEALTH PROMOTION
[63] Answer as either true (T) or false (F).
a) T Immunizations are effective in decreasing the incidence of childhood infectious diseases.
b) F Because all states require immunizations for children attending school, obtaining parental
informed consent is not necessary.
c) F The preferred site for intramuscular injections in infants is the deltoid.
d) T Age-appropriate doses of acetaminophen may be given if the child experiences discomfort
following an immunization.
e) T When administering more than one injection, the nurse should administer the vaccines
using separate syringes at different sites.
f) T An otherwise healthy child with a low-grade fever can receive immunizations.
g) F Because of the threat of bioterrorism, the American Academy of Pediatrics recommends
the routine administration of the smallpox vaccine for all children who are not
immunocompromised.
h) F The Haemophilus influenzae type b (Hib) vaccine has significantly reduced the incidence
of seasonal influenza among infants and young children.

Fill in the blanks.

[64] In general, children who are immunocompromised should not receive live vaccines.
[65] Because of the possibility of anaphylactic reactions, it is essential to have 0.01 mg/kg/dose of
epinephrine 1:1000 available while administering immunizations.

[66] Match each nutrient with its function.

C Carbohydrates a) Building and maintaining body tissue
E Fats b) Transporting nutrients to and waste away
A Proteins from cells
B Water c) The primary dietary source of energy
D Vitamins/minerals d) Regulating metabolic processes
e) A secondary dietary source of energy

[67] Why is dietary fat intake not restricted in children younger than 2 years? Infancy is a period of
rapid growth, and infants need sufficient calories to support this growth

[68] After the age of 4 years, fat intake should be between 25 % and 35 % of daily calories.

[69] Why is it important to gather data about a hospitalized child's food preferences? to ensure that the
child will not be further stressed by unfamiliar foods in the hospital

[70] List three methods of obtaining a dietary history. 24 hour dietary recall, food frequency
questionnaire, food diary.

[71] What is the leading cause of death in children in the United States? Unintentional Injuries

Chapter 6: Health Promotion for the Infant

[72] Match the term with the correct definition.

E Asphyxiation d) Use of the index finger and thumb to pick
I Critical milestones up objects
A Developmental milestones e) State of suffocation that severely
B Egocentrism compromises oxygen delivery
H Mistrust f) Realization that things continue to exist
F Object permanence when out of sight
K Parent-infant attachment g) Distress experienced when the infant is
D Pincer grasp separated from caregivers or meets
J Sensorimotor stage unfamiliar persons
G Stranger anxiety h) Negative resolution of Erikson's first
C Trust developmental task
i) Developmental benchmarks that, if not
a) Benchmarks of development that indicate reached, necessitate a full developmental
that the child is normally developing assessment
b) Inability to see another person's point of j) Piaget's first stage of cognitive development
view k) Sense of connection between the parent and
c) Emotional foundation on which a healthy infant
personality is built

GROWTH AND DEVELOPMENT OF THE INFANT

[73] Next to each activity, match the age at which the behavior typically first appears. Answers may
be used more than once.

8-9 Begins to obey simple commands a) 1 to 2 months

4-5 Crying becomes differentiated
b) 3 months
6-7 Sits alone
1-2 Smiles in response to others c) 4 to 5 months
6-7 Birth weight doubles
d) 6 to 7 months
8-9 Cruises around the furniture
6-7 Begins to demonstrate stranger anxiety e) 8 to 9 months
6-7 Is alert for 1.5 to 2 hours
f) 12 months
1-2 Behavior is mostly reflexive
4-5 Can breathe when the nose is obstructed
8-9 Pincer grasp develops
12 Birth weight triples
4-5 Turns from the abdomen to the back
8-9 Has a beginning sense of object permanence

[74] Infants are vulnerable to respiratory infections because of immature immune systems and small
collapsible airways.

[75] During infancy, the heart rate decreases, while the blood pressure increases.

[76] Breast milk provides additional immunoglobulin A (lgA) protection to the infant.

[77] At what age does the gastrointestinal system have the ability to digest and absorb fats at the same
level of an adult? 6-9 months

[78] Because infants' renal systems are immature, they are at risk for Fluid and Electrolyte
imbalances.

[79] Match each substage of Piaget's sensorimotor stage with its description.
D Reflex activity a) Actions become intentional
C Primary circular reactions b) Begins to have sense of object permanence
A Secondary circular reactions c) Activities become less reflexive and more
B Coordination of secondary schemata controlled
d) Behavior is dominated by reflexes

[80] Answer as either true (T) or false (F).

a) F Depth perception is present at birth.
b) F Lack of eye muscle control at 2 months requires evaluation.
c) T All newborns should be screened for hearing problems.
d) T By 10 months, an infant should respond to his or her name.
e) T An infant's social smile is a communication tool.
f) F Vocalization is a reflexive activity.
 g) F Infants' expressive language is more advanced than receptive language.

[81] Briefly describe how an infant develops a sense of mistrust from early interactions.
When needs are not met they develop a sense of mistrust

[82] How is the parent-infant attachment strengthened?

Through mutually satisfying interactions. Parents strive to meet baby’s needs and baby responds
well to them

[83] Why does stranger anxiety begin at approximately 6 to 7 months?

By this age infants have become attached to their caregivers and have the cognitive ability to
differentiate them from others

HEALTH PROMOTION FOR THE INFANT AND FAMILY

[84] Transplacental passive immunity lasts approximately 3 months.

[85] Infant formula lacks the immunologic properties and easy digestibility of breast milk.

[86] Provide a minimum of three examples of mothers who should not breastfeed their infan.ts
Mothers who use illegal drugs or certain medications
Mothers with hiv
Mothers with untreated TB

[87] What is weaning?

Transition from breastfeeding/bottle feeding to drinking from a cup

[88] Describe how to introduce solid foods into an infant's diet.

When infant is showing signs of readiness and introduced in small amounts for several days

[89] Answer as either true (T) or false (F).

a) F Infants typically have 12 teeth by their firs-t birthday.
b) F Baby aspirin is the drug of choice for alleviating teething discomfort.
c) F Parents can use a washcloth and a tiny bit of toothpaste to clean their infant's teeth.
d) T Bottle mouth caries are preventable.
e) T Botulism is associated with an infant's intake of honey.

[90] List four recommendations for a safe sleep environment from the American Academy of
Pediatrics for preventing Sudden Infant Death Syndrome (SIDS).
Back to sleep
Firm mattress
Keep loose bedding and toys from inside crib
Do not expose infant to smoke
Avoid overheating
[91] When riding in a car, infants weighing less than 20 lbs should be placed in the back seat in a rear
facing car safety seat.

[92] Sunscreen should be applied to an infant's skin starting at the age of 6 months.

[93] Temperature settings on hot water heaters should be no higher than 120 degrees Fahrenheit.

[94] Gates at the top and bottom of the stairs should be in place when the child starts to crawl.
[95] List at least four foods that pose an asphyxiation risk for infants.
Hot dogs
Chewing gum
Hard candy
Peanuts

[96] List four suggestions that may help parents reduce their infants' irritability.
Carrying the infant
Taking the infant for a car ride
Gently patting the infant on the back
Placing the infant in an infant swing

Chapter 7: Health Promotion During Early Childhood

[97] Match the term with the correct definition.

I Associative play performed
D Autonomy c) Reasoning from particular to particular
F Caries d) Ability to independently function
e) Playing alongside, but not with, others
N Cooperative play
f) Tooth decay
K Dysfluency g) Ability to allow a mental image to represent
B Irreversibility something that is not present
M Negativism h) Decreased appetite related to a decreased
E Parallel play caloric need
H Physiologic anorexia i) Group play without goals
A Regression j) Need to maintain sameness
k) Disorders in the rhythm of speech in which
J Ritualism
the child knows what to say but is unable to
L Symbolic play do so
G Symbolic thought l) Games or play that represents an issue to be
C Transductive reasoning addressed
a) Return to a behavior characteristic of an m) Opposition or resistance to the direction of
earlier stage of development others
b) Inability to undo an action that has been n) Organized play with group goals

GROWTH AND DEVELOPMENT DURING EARLY CHILDHOOD

[98] During early childhood, the average weight gain is 5 lbs/yr.

[99] Children reach one half of their adult height between the ages of 2 and 3 years

[100] All 20 deciduous teeth are present by the age of 2.5 years. (30 months)

[101] For each of the following, write (T) if the behavior first occurs during toddlerhood or (P) if it first
occurs during the preschool years.
a) T Learns to walk well
b) P May have imaginary friends Handedness clearly established
 c) T Exhibits negativism as an expression of independence
d) T Object permanence firmly established
e) T Separation anxiety peaks during this period
f) P Gender identity well established
g) P May start to use aggressive speech
h) T Is in the intuitive substage of Piaget's preoperational stage
i) P Masturbation is common
j) T Is an avid climber
k) T Obeys rules out of self-interest
l) T Can brush teeth with supervision

[102] Match each characteristic of preoperational thinking with its example.

A Animism it back together.
D Centration c) Carla's brother is in the hospital. She
E Egocentrism believes she made him sick because she did
B Irreversibility not want to play with him. ·
C Magical thought d) Diego can follow only one direction at a
time.
a) Aaron believes the TV is watching him e) Elgin took Fatima's toy and cannot
while he sleeps. understand why Fatima is upset.
b) Beth took the toy truck apart and cannot put

HEALTH PROMOTION FOR THE TODDLER OR PRESCHOOLER AND FAMILY

[103] Answer as either true (T) or false (F).
a) T Young children should drink two cups of whole milk a day.
b) T An appropriate serving size for solid food for the young child is one tablespoon of solid
food per year of age.
c) F It is appropriate to substitute fruit juice but not fruit drinks for milk.
d) F A toddler who eats little solid food but drinks a quart of milk per day is meeting
recommended dietary allowances (RDAs).
e) F Food jags cause physiologic anorexia.

[104] When should a child first visit the dentist?

6 months after first tooth erupts

[105] Why are bedtime rituals important for young children?

they provide a sense of security

[106] Explain the difference between nightmares and night terrors. Nightmares are frightening dreams
that wake the child, night terrors do not wake the child. The child may scream out of his or her sleep
and have the eyes open. The child does not remember night terrors when awake.

[107] A child learns self-control through discipline and limit setting

[108] How can parents prevent drownings? They should never leave young children alone in or near
bathtubs or swimming pools or near buckets of water. They should keep toilet lids closed.
[109] Why is the use of booster seats in the car recommended for preschoolers who weigh more than 40
lbs? Booster seats raise the child high enough so that the car is lap, belts and shoulder harnesses are
correctly positioned over the child smaller body

[110] What should preschoolers be taught to do in the event that their clothes catch on fire? They
should be taught to stop, drop, and roll.

[111] What do parents need to know about firearm safety? Guns should always be kept unloaded. They
should be stored in locked cabinets with trigger guards in place

[112] What is included in teaching children about sexual abuse? After teaching a child about what
inappropriate touching behavior is, teach him or her to immediately tell him adult if someone is
inappropriate touching him or her, reinforce that he or she should tell another adult even if the
offending adult is a friend or relative, or tells a child not to tell anyone explain that here she needs to
keep telling as many adults as necessary until the inappropriate behavior stops

[113] Most children are ready for toilet training by 24 to 30 months. What are reasons one would
postpone toilet training in a child? If the family is undergoing a change, such as moving or the birth
of another child, it might be better to postpone toilet training until the child has adjusted to the change

[114] List four strategies parents can use to decrease the frequency of temper tantrums. 1) limit
exposure to situations that the child finds hard to handle, 2) anticipate the child’s fatigue, 3) anticipate
the child's hunger, 4) offer choices.

[115] How can parents deal with sibling rivalry when a new baby is coming into the household? Before
the birth of the sibling, include the child in preparation for the new baby. Read stories about the new
sibling. Teach about the changes that may occur. Allow the child to express his or her feelings. Refer
to the baby as “ours”. After the birth, parents should spend a period of uninterrupted private time with
the older sibling each day.

[116] How can parents help a child who stutters? Speak slowly and pause frequently. Avoid pressuring
the child to communicate immediately or rapidly. Notice what situations and environmental factors
have a negative effect on the child’s fluency. Do not complete the child’s sentences. Do not draw
attention to the child’s speech

Chapter 8: Health Promotion for the School-Age Child

[117] Match the term with the correct definition.

E Caries a) Misalignment of teeth
B Conservation b) Ability to understand that certain properties
A Malocclusion of objects remain the same despite changes
D Menarche in appearance
C Self-care children c) Children who care for themselves after
school
d) Onset of menstruation
e) Tooth decay

GROWTH AND DEVELOPMENT OF THE SCHOOL-AGE CHILD

[118] Answer as either true (T) or false (F).
a) F Throughout the school-age years, boys are consistently taller and heavier than girls.
 b) T The onset of puberty is signaled by the adolescent growth spurt.
c) F Tonsil enlargement in the school-age child is considered an abnormal finding.
d) F All permanent teeth are in place by the age of 12 years.
e) F Menarche occurs later in females who are obese.

Short answer and fill in the blank questions.

[119] Why is active play important for school-age children?
Active play increases coordination, refines motor skills, serves as a foundation for physical
fitness as an adult, improves cardiovascular (CV) fitness, increases strength and flexibility, and
aids in the prevention of obesity.

[120] Why are children more prone to dehydration than adults?

Children have higher metabolic rates and limited ability to sweat.

[121] Reversibility allows children in the concrete operational stage to anticipate the results of their
Actions.

[122] Children understand the principle of conservation of weight before they understand conservation
of volume.

[123] Why is collecting stickers an appropriate activity for school-age children?

Cognitively, they are able to arrange things in log-ical order and are able to recall similarities and
differences.

[124] How do friendships change as school-age children mature?

Children learn that friendship is more than just being together. They begin to share problems and
give each other emotional support. They develop a sense of loyalty.

[125] Why do middle ear infections occur less often in school-age children than in younger children?
Their eustachian tubes have grown.

[126] How do children develop a sense of industry?

By learning to do new things and by learning to do them well.

[127] How is the developmental task of industry related to self-esteem?

As children learn to do things well, they become more confident and feel good about themselves.

[128] Why are rules important to school-age children?

Rules provide predictability and security. By con-forming to external rules, children learn self-
disci-pline and internalize values.

[129] Briefly describe why children obey rules in each of the following stages of moral development.
a) Preconventional, stage 2: a. Child obeys to avoid punishment.
b) Conventional, stage 3: b. Child obeys to avoid disapproval or to please others.
c) Conventional, stage 4: c. Child obeys out of respect for authority.

HEALTH PROMOTION FOR THE SCHOOL-AGE CHILD AND FAMILY

[130] School-age children need how many servings of the following foods each day?
 a) 5 oz. of grains
b) 2.5 cups of vegetables
c) 1.5 cups of fruits
d) 5 oz. of protein
e) 3 cups of dairy products

[131] A 6-year-old needs approximately 12 hours of sleep, whereas a 12-year-old needs 9 to 10 hours.

[132] How can parents foster a sense of responsibility in their children

Through the use of natural consequences related to actions

[133] List a minimum of three strategies parents can use to help their child succeed in school.
Positive reinforcement or reward for school attendance
Encouraging and maintaining peer contact
Emphasizing the positive aspects of school

[134] How can nurses act as advocates for self-care children?

Nurses can serve as child advocates by working to develop expanded after-school child-care
programs in the community

[135] What can parents do to prevent childhood obesity?

* Avoid using food as rewards
* Establish consistent times for meals and snacks and discourage in-between eating
offer only healthy food options (ask the child to choose between an apple or popcorn, not apple or a
cookie)
*Avoid keeping unhealthy food in the house and minimize trips to fast-food restaurants
* Be a role model by improving your own eating habits and levels of activity
* Encourage the child to do fun, physical activities with the family
* Praise the child for making appropriate food choices and increasing physical activity levels

Chapter 9: Health Promotion for the Adolescent

[136] Match the term with the correct definition.

E Adolescence b) Acquisition of psychosocial, sexual, and
D Autonomy vocational identity
I Egocentrism c) Period before sexual maturity
B Identity formation
d) Capacity to be self-governing
F Primary sexual characteristics
J Puberty e) Transition from childhood to adulthood
C Pubescence f) Internal and external reproductive organs
A Reproductive maturity g) Stages of sexual maturation
H Risk-taking behavior
h) Behavior that predisposes a person to harm
K Secondary sexual characteristics
G Sexual maturity rating (SMR) i) Concern with self
j) Achievement of reproductive maturity

a) Spermatogenesis in males and menstruation k) Physical characteristics of males and

in females females that have no direct role in
 reproduction

ADOLESCENT GROWTH AND DEVELOPMENT

[137] Physical maturation in girls occurs with the onset and establishment of menstruation .

[138] Another term for the adolescent growth spurt is: puberty

[139] In girls, the appearance of Breast Buds (Thelarche) is the first sign of ovarian functioning.

[140] Breast enlargement in boys is called: Gynecomastia

[141] An adolescent's chronologic age provides less information about physical development than does
sexual maturity rating.

[142] In boys, the first sign of pubertal changes is: Testicular enlargement in response to testosterone
secretion.

[143] The secretion of sex hormones (Estrogen in girls and Testosterone in boys) stimulates the
development of breast tissue, pubic hair, and genitalia.

[144] List a minimum of five effective strategies the nurse can use when communicating with teens.
*Be patient and flexible
* Maintain confidentiality
* Be an advocate, but do not take sides against a parent
* Listen non judgmentally, keeping criticism to a minimum
* Know adolescent development ; consider how a teen will look to peers

[145] In adolescent psychosocial development, what is meant by the "moratorium"?

period granted to teens as they are experimenting with roles and not yet ready to make permanent
commitments
[146] What functions do adolescent peer groups serve?
they provide safety and validation as teens emotionally move away move away from the family
and experiment with new roles

[147] For these milestones, identify the typical period of adolescence (early, middle, or late) during
which the described behavior is most likely to occur.
a) early Best friends are of the same gender.
b) early Adolescents react to an imaginary audience.
c) late Emancipation from parents is a major issue.
d) middle Adolescents over identify with glamorous role models.
e) middle Conflicts with parents escalate.
f) late Conformity with a peer group is less important.
g) early,middle Gang membership brings security.
h) middle This is the most frustrating time for parents.

HEALTH PROMOTION FOR THE ADOLESCENT AND FAMILY

[148] Answer as either true (T) or false (F).
a) T Lack of self-esteem and peer pressure influence a teen's sexual behavior.
b) F Adolescents require fewer calories during peak height velocity (PHV).
 c) T When transporting an avulsed tooth, place it in a container of milk.
d) F Because of PHV, adolescents require at least 10 hours of sleep per night.
e) T Regular exercise promotes healthy sleep patterns.
f) T More teens die from unintentional injuries than from all other causes of death combined.
g) T Adolescents with tattoos may be injured during magnetic resonance imaging.

Fill in the blank with appropriate terms or provide a short answer as indicated.
[149] The USDA recommends an intake of 1000 cal/day for adolescent girls and 2200 cal/day for
adolescent boys.

[150] Adolescents who use tanning salons are at risk for eye injury, premature aging, and increasing
risk of skin cancer of all types.

[151] In addition to depression, risk factors for teen suicide include:

poor impulse control, poor school performance, poor mental health, family disorganization,
conduct disorders, and substance abuse

[152] Answer as either true (T) or false (F).

a) ___T_ A teen's cognitive ability affects contraceptive practices.
b) __T__ Studies indicate that adolescents believe that engaging in oral sex is more socially
acceptable and less risky than vaginal intercourse.
c) _T___ Ideally, contraceptive education should include both partners.
d) _T___ All threats of suicide by an adolescent should be taken seriously. Violence is an innate
human behavior.
e) _T___ Homicide is the second leading cause of death among teens aged 15 to 19 years.

Chapter 10: Heredity and Environmental Influences on Development

[153] Match the heredity term with the correct definition.

___C__ Allele c) Alternate gene form
__E___ Karyotype d) Variation in a gene that affects function
__I___ Monosomy e) Chromosomes arranged from largest to
__D___ Mutation smallest pair.s
__A___ Polymorphism f) One extra chromosome present in each body
__B___ Polyploidy cell
__H___ Somatic cell g) All or part of a chromosome attached to
___J__ Teratogen another
___G__ Translocation h) Body cells other than germ cells
__F___ Trisomy i) Cells with only one chromosome
j) Agent that causes or increases the risk for a
a) Common gene variation birth defect·
b) Cell with an added set of chromosomes

HEREDITARY INFLUENCES
[154] Explain how deoxyribonucleic acid (DNA), genes, and chromosomes are related.
DNA is the basic building block genes. Specific segments of DNA from a gene, and many genes
form a chromosome

[155] The explosion of knowledge about the genetic basis for disease raises many legal and ethical
issues. How can this knowledge affect the following?
a) Privacy: Genetic information about an individual has implications for other family members.
b) Self-esteem: A person with a genetic problem may feel inferior or guilty about passing it on to his
or her children
c) Level of anxiety: a person with a genetic abnormality who is currently asymptomatic may
experience long term anxiety waiting for the disease to occur
d) Health insurance coverage: a person with a genetic abnormality may be denied insurance
coverage or be forced to pay exorbitant premiums.

[156] For each type of single-gene abnormality, describe the conditions necessary for a child to be
affected and specify any sex differences.
a) Autosomal recessive: the child must receive a copy of autosomal recessive gene from both
parents, no sex differences
b) Autosomal dominant: the child may receive a copy of autosomal dominant genre from either
parent, no sex difference
c) X-linked recessive: because females are camera, the child receives the abnormal gene from the
mother. Males are affected because they do not have a compensating normal x chromosome, the
affected father will pass abnormality genes to their daughter.

[157] Answer as either true (T) or false (F).

a) T Sickle cell disease follows an autosomal-recessive pattern of development.
b) F Type O blood follows an autosomal-dominant pattern of development.
c) F AJI sons of a father with hemophilia will inherit the disease.
d) T Turner syndrome is an example of a numerical abnormality.
e) F Fragile X syndrome is the most common form of female intellectual disability.

MULTIFACTORIAL DISORDERS
[158] Describe two characteristics typical of multifactorial birth defects.

They are present and detectable at birth. They tend to be single, isolated defects.

[159] What factors influence the risk for the occurrence of a multifactorial disorder?

The number of affected close relatives, severity of dis-order in other family members, sex of affected
person, geographic location, season of year

ENVIRONMENTAL INFLUENCES
[160] When should a rubella immunization be administered to a woman of childbearing age?
At least 4 weeks before conceiving
[161] In prescribing drugs for pregnant women, what must the nurse practitioner balance?
The woman’s need for the therapeutic effects of the drug and how the drug will affect the fetus

[162] When a pregnant woman requires an urgent X-ray study, her lower abdomen is Protected by a
lead apron
[163] Why should pregnant women avoid saunas and hot tubs?
Maternal hyperthermia is a teratogen.

GENETIC COUNSELING
[164] Genetic counseling focuses on the entire family.

[165] Genetic counseling is considered Nondirective because the counselor does not tell the patient
what decision to make.

NURSING CARE OF FAMILIES CONCERNED ABOUT BIRTH DEFECTS

[166] How do nurses in the following practices provide care related to genetics?
a) Women's health nurses: identify women who may benefit from genetic counseling.
b) Antepartum nurses: Identify women who may benefit from genetic coun-seling; provide support
if they receive abnormal results; support their decisions; teach
c) Neonatal nurses: Evaluate family’s perception of the problem; explain diagnostic tests and
results; make referral
d) Pediatric nurses: Support family; make referrals

Chapter 11: Reproductive Anatomy and Physiology

[167] Match the term with the correct definition.

_A___ Linea tenninalis b) Spontaneous release of seminal fluid from
_B___ Nocturnal emissions the penis during sleep
_E___ Perineum c) Small ridges or folds of tissue in the female
_C___ Rugae vagina and on the male scrotum
_D___ Vulva d) Collective term for all of the female external
reproductive organs
a) Imaginary line dividing the upper (false) e) Posterior part of external female
pelvis from the lower (true) pelvis reproductive organs

[168] Match each structure with its function(s). Some letters may be used more than once.
___D_ Acini cells the testes
__C__ Bartholin's glands c) Promote the lubrication of the vagina for
_A___ Corpus cavernosum coitus
_A___ Corpus spongiosum d) Produce milk from substances extracted
H____ Leydig cells from blood
_E___ Montgomery's tubercles e) Secrete a substance to keep nipples soft
_i___ Myoepithelial cells during breastfeeding
__F__ Scrotum f) Regulate the temperature of the testes to
__B__ Sertoli cells promote normal sperm formation
__G__ Skene's glands g) Lubricate the female's urethra
h) Secrete testosterone in the male
i) Eject milk into the ductal system of the
a) Enable the erection of the penis for coitus breast
b) Nourish sperm during their formation within
KEY CONCEPTS
[169] What mechanism prevents the onset of puberty before the proper time?
An unknown area of the brain prevents the young child’s hypothalamus from responding to estrogen and
testosterone secretion by the ovaries or testes. Without the gonadotropin-releasing hormone from the
hypothalamus, further estrogen or testosterone secretion ceases.
[170] The period when reproductive organs become fully functional is called
_puberty______________. It begins at an approximate age of __8-13_______ years in girls and an
approximate age of ________9.5 to 17___ years in boys.

[171] The first outward change of puberty in girls is breasts. The first outward change of puberty in
boys is testes and penis.

[172] Girls usually experience their first menstrual period at approximately 9-16 years.

[173] What factors cause the average male to be taller than the average female at physical maturity?
Testosterone

[174] Explain the importance of each type of smooth muscle fiber in the myometrium. Where is each
type primarily located?
Longitudinal fibers
a) Importance: designed to expel the fetus efficiently toward the pelvic outlet during birth
b) Location: found mostly in the fundus (myometrium)

c) Interlacing (figure-eight) fibers

Importance: these fibers contract after birth to compress the blood vessels that pass between them
to limit blood loss
Location: myometrium

d) Circular fibers
Importance: prevents reflux of menstrual blood tissue into the fallopian tubes,promote normal
implantation of the fertilized ovum by controlling its entry into the uterus,and retain the fetus
until appropriate time of birth
Location: myometrium

[175] Fertilization normally occurs in the fallopian tube.

[176] When are female gametes formed? - when the X bearing spermatozoa fertilize the ovum
When are male gametes formed? - when the y bearing spermatozoa fertilizes the ovum

[177] Describe events in each phase of the ovarian cycle.

a) Follicular phase- period during which the ovum is mature.It begins with the first day of
menstruation and ends 14 days later in a 28 day cycle.
b) Ovulatory phase- near the middle of a 28 day reproductive cycle,approximately 2 days before
ovulation,LH secretion rises markedly.Secretion of FSH also rises but less than LH does.
c) Luteal phase- after ovulation and under the influence of LH,the remaining cells of the old follicle
persist for approximately 12 days as a corpus luteum.

[178] Describe events in each phase of the endometrial cycle.

a) Proliferative phase- takes place as the ovum matures and is released during the first half of the
ovarian cycle.After completion of a menstrual period,the endometrium is very thin,with only the
 basal layer of cells remaining.
b) Secretory phase- occurs during the second half of the ovarian cycle as the uterus is prepared to
receive a fertilized ovum.
c) Menstrual phase- if fertilization does not occur,the corpus luteum regresses,and its production of
estrogen and progesterone falls.

[179] Why might a man who usually wears very tight underwear have a problem with infertility?- the
blood circulation gets reduced due to the tight elastic. It can reduce the blood flow to the penis and
testicles and also to your thighs. Less blood flow to the penis can lead to erectile dysfunction (ED).
Blood flow to testicles can also be compromised.

[180] The sex of an infant will be female unless:

a) two X chromosomes are received from the mother.
b) the Y chromosome is received from the father.
c) conception occurs during the last half of the female reproductive cycle.
d) the mother's ovary produces testosterone early in pregnancy.

[181] The primary purpose of gonadotropin-releasing hormone (GnRH) is to stimulate:

a) the development of the woman's breasts for lactation.
b) growth of pubic and axillary hair.
c) breakdown of the endometrium during the menstrual flow.
d) secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior
pituitary gland.

[182] The first outward change of puberty in girls is:

a) rapid growth to reach the adult height and weight.
b) enlargement and development of the breasts.
c) onset of menstruation.
d) increase in clear vaginal secretions.

[183] Choose the girl who is most likely to have secondary amenorrhea.
a) Amanda, a 15-year-old, who is approximately 10% above her ideal weight for height.
b) Brittany, a 17-year-old, who is preparing to compete in a national gymnastic tournament.
c) Chloe, a 16-year-old, who had her first menstrual period 1 year ago at the age of 15 years..
d) Deanna, a 16-year-old, who had her first signs of puberty at the age of 10 years.

[184] Males are usually taller than females when they reach their adult height because their: .
a) growth in height occurs early in puberty and continues for a short time after puberty.
b) secretion of testosterone delays the closure of the epiphyses of the long bones.
c) puberty changes begin approximately 2 years later than in the average female.
d) rapid increase in height begins later in puberty and continues for a longer time.

[185] The layer of uterine muscle that is most active during labor is composed of what kind of fibers?
a) Longitudinal
b) Interlacing
c) Circular

[186] The layer of uterine tissue that responds to cyclic changes in hormones that are secreted by the
pituitary gland is the:
a) perimetrium.
b) myometrium.
 c) endometrium.

[187] Conditions that cause the fallopian tubes to be narrower than normal may result in:
a) excessive cramping and bleeding during menstruation.
b) increased likelihood of pregnancy during each cycle.
c) more rapid propulsion of the ovum through the tube.
d) implantation of a fertilized ovum within the tube (see Chapter 25).

[188] Extra follicles that remain after ovulation:

a) release their ovum during the last half of the reproductive cycle.
b) resume maturation during the next reproductive cycle.
c) may be fertilized during another reproductive cycle.
d) are unresponsive to stimulating hormones and do not mature.

[189] Menstruation occurs because the:

a) hormone stimulation from the corpus luteum ceases.
b) blood vessels in the uterine lining become too long and twisted. ·
c) corpus luteum increases estrogen and progesterone production.
d) ovum has been passed from the woman's body.

[190] Milk is manufactured within the _____ of the breast.

a) lactiferous ducts
b) alveoli
c) myoepithelium
d) Montgomery's tubercles

[191] The primary purpose of the cremaster muscle is to:

a) eject milk into the lactiferous ducts of the breasts.
b) maintain the uterus in the anteflexed position.
c) keep the testes cooler than the rest of the body.
d) expel seminal fluids to nourish the sperm at ejaculation.

Chapter 12: Conception and Prenatal Development

[192] Match the term with the correct definition.

_C_ Autosome b) —-Developing baby from weeks 3 to 8
_A__ Conceptus c) —-Non-sex chromosome
__G_ Corpus luteum d) —-Reproductive cell
_B__ Embryo e) —-Ordinary body cell
_D__ Gamete f) —-Structure that provides nourishment for
_I__ Mitosis the developing baby
_H__ Oogenesis g) —-Cells that remain after ovum formation
__J_ Ovulation and secrete estro- gen and progesterone
__F_ Placenta h) —-Formation of female gametes
__E_ Somatic cell i) —-Cell division in body cells
j) —-Release of the mature ovum from the
a) —-Fertilized ovum ovary

KEY CONCEPTS
[193] Compare mitosis with meiosis in the following ways:
Factor Mitosis Meiosis
Type of cell involved Somatic cells Reproductive cells
Number and type of 46 22 autosomes, 1 sex
chromosomes in each resulting chromosome
cell

[194] Table: Compare oogenesis with spermatogenesis in the following ways:

Factor Oogenesis Spermatogenesis
Number and type of 22 autosomes and 1 sex (X) 22 autosomes and 1 sex (X or
chromosomes in each mature chromosome Y) chromosome
gamete
Number of gametes that result 1 4
from each primary cell
When gametogenesis begins and Begins during puberty and into Begins during puberty and lasts
ends during life menopause until 60s/70s in males

[195] What are the two major occurrences immediately after fertilization?
• Changes in the zona pellucida surrounding the ovum prevent other
sperm from entering.
• The ovum, which has been suspended in the middle of its second
meiotic division, completes meiosis.

[196] List three reasons that the fundus is the best area for implantation.
• The upper uterus is richly supplied with blood for optimal fetal gas
exchange and nutrition.
• The uterine lining is thick in the upper uterus, preventing the placenta
from attaching so deeply that it does not easily detach after birth.
• Implantation in the upper uterus limits blood loss after birth
because strong interlacing muscle fibers in this area compress open
vessels after the placenta detaches.

[197] List the three germ layers and structures that develop from each.
○ Ectoderm: Brain, spinal cord, peripheral nervous system, pituitary gland, sensory epithelium
of the eye, ear, and nose, epidermis, hair, nails, subcutaneous gland, mammary gland, tooth
enamel
○ Mesoderm: cartilage, bone, connective tissue, muscle tissue, heart, blood vessels, blood cells,
lymphatic system, spleen, kidneys, adrenal cortex, ovaries, testes, reproductive system, lining
membranes (pericardial, pleural, peritoneal)
○ Endoderm: Lining of GI & respiratory tract, tonsils, thyroid, parathyroid, thymus, liver,
pancreas, lining of urinary bladder and urethra, lining of ear canal
[198] When during prenatal development does each event occur?
a) Closure of the neural tube - 4 weeks
b) The heart contains four chambers - 6 weeks
c) All abdominal organs are within the abdominal cavity - 10 weeks
d) External ear development begins - 6 weeks
 e) Fetal sex is apparent by the external genitalia - 12 weeks
f) Fetal movements are felt by the mother - 16 - 24 weeks
g) Surfactant production begins - 21 - 24 weeks

[199] Describe each of these fetal structures or substances and state their purpose.
a) Vernix caseosa - Creamy skin covering to lubricate and protect the fetal skin from amniotic fluid
b) Lanugo - Fine, downy hair that helps vernix adhere to the skin.
c) Brown fat - Heat-producing fat found on the back of the neck, behind the sternum, and around
kidneys
d) Surfactant - Surface-active lipid substance that helps the alve-oli remain slightly open between
breaths to ease the work of breathing.

[200] What is the difference between the fertilization and gestational ages?
Fertilization age is calculated in weeks from the actual time of conception. Gestational age is
calcu-lated from the first day of the woman’s last menstrual period. Gestational age is approximately 2
weeks longer than the fertilization age.

[201] Explain how each of the following mechanisms allows the fetus to thrive in the relatively low-
oxygen environment of the uterus.
a) Fetal hemoglobin and hematocrit - High fetal hemoglobin and hematocrit give the fetus more
oxygen-carrying capacity; fetal hemo-globin can carry 20% to 50% more oxygen than adult
hemoglobin.
b) Relative fetal and maternal blood carbon dioxide levels - Fetal carbon dioxide quickly diffuses
into the mother’s blood, causing her blood to become more acidic and the fetal blood to become
more alkaline; this allows the fetal blood to more readily combine with oxygen.

[202] Describe how the passage of maternal immunoglobulin G (IgG) antibodies can be either
beneficial or harmful to the fetus.
a) Beneficial - Provides the newborn with temporary passive immunity to diseases to which the
mother is immune.
b) Harmful - Maternal blood-type antibodies may cross the pla-centa and destroy incompatible fetal
erythrocytes.

[203] Explain the function of each placental hormone.

a) Human chorionic gonadotropin (hCG) - Causes persistence of the corpus luteum to main-tain
estrogen and progesterone secretion during early pregnancy and causes the fetal testes to secrete
testosterone to stimulate the development of normal male reproductive structure
b) Human placental lactogen (hPL), now called human chorionic somatomammotropin - Promotes
normal growth and nutrition of the fetus, stimulates maternal breast development, and makes
more glucose available to the fetus by reducing maternal insulin sensitivity and glucose
utilization.
c) Estrogen - Causes the enlargement of the uterus and breast, growth of the breasts’ ductal system,
and enlarge-ment of the fetal external genitalia
d) Progesterone - Changes the endometrium into decidua to nour-ish conceptus before the placenta
is established, reduces uterine contractions, and stimulates breast growth and the development of
the breast alveoli and ductal system.

[204] State the three functions of amniotic fluid: Cushions the fetus from impacts; provides a stable
temperature; promotes normal fetal growth and devel-opment (promotes symmetrical development,
prevents membrane adherence, and allows fetal movement)
[205] Explain the umbilical cord structure and function.
a) Umbilical vein - Carries oxygenated blood and nutrients from the placenta to the fetus
b) Umbilical arteries (two) - Carries deoxygenated blood and waste products from the fetus to the
placenta
c) Wharton's jelly - Protects the cord vessels from stretching or pres-sure that would interrupt flow

[206] Explain the factors that cause each of these fetal circulatory shunts to close after birth and the
eventual outcome for each.
a) Foramen ovale - As the infant breathes, resistance to blood flow to the lungs decreases and the
foramen ovale closes; tissue proliferation causes it to fill the septum between the right and left
atria.
b) Ductus arteriosus - Increasing arterial oxygen levels cause constric-tion; becomes a ligament
c) Ductus venosus - Cessation of umbilical cord blood flow with birth causes it to become
nonfunctional; it becomes a ligament.

[207] Table: Describe monozygotic and dizygotic twinning in the following terms:
Factor Monozygotic Dizygotic
Number of ova and sperm 1 ovum and 1 sperm 2 ova & 2 sperm
involved
Genetic component Identical genes like any other siblings
Sex same sex may be same or different sex
Hereditary tendency no hereditary influence known Hereditary (and ethnic)
tendency often found
Number of amnions and varies according to time when always has 1 amnion and 2
chorions inner cell mass divides into two, chorions
but most often 2 amnions and 1
chorion

CLINICAL JUDGMENT
[208] A 32-year-old woman is 12 weeks pregnant and is having a prenatal checkup with her
obstetrician. She has had a healthy pregnancy so far and does not report any concerns. Which
teaching statements are most appropriate to provide to the woman at this stage in her pregnancy?
Select all that apply.
a) "Your first trimester is now complete."
b) "You should have experienced quickening at this point in your pregnancy."
c) "We will be able to hear fetal heart tones at the level of the umbilicus."
d) "The worst of your morning sickness should be behind you now."
e) "At this point in your baby's development, the sucking reflex is present."
f) "On ultrasound, we likely can determine the sex of the baby, as external genitalia can be
distinguishable by appearance."
g) "The baby's arms and legs are long and thin."
h) "The baby is now producing urine, which becomes part of the amniotic fluid."
i) "Your baby's toenails are present and the fingernails extend all the way to the fingertips."

[209] The embryo is fully implanted in the uterus on which day after conception.
a) 3
b) 6
c) 10
d) 15
[210] An important purpose of seminal fluid is to:
a) digest microorganisms in the female digestive tract.
b) prevent the premature movement of sperm tails.
c) protect sperm from the acidic vaginal environment.
d) transport the sperm into the uterine cavity.

[211] Fertilization is complete when:

a) the fusion of the sperm and ovum nuclei occurs.
b) sperm enters the ovum in the fallopian tube.
c) the fertilized ovum has its first cell division.
d) the morula fully implants into the uterine lining.

[212] Which fetal circulatory carries blood with the highest oxygen concentration.
a) Umbilical artery
b) Umbilical vein
c) Ductus arteriosus
d) Pulmonary vein

Chapter 13: Adaptations to Pregnancy

[213] Match the term with the correct definition.

F Amenorrhea d) Irregular pink to purple streaks caused by
B Chloasma lineal tears in the connective tissue; "stretch
C Hyperemia marks"
A Multigravida e) Decrease in hematocrit that occurs because
E Physiologic anemia of pregnancy the plasma volume expands more than the
D Striae gravidarum red blood cell volume
G Ambivalence f) Absence of menstruation
L Couvade g) Conflicting feelings
I Introversion h) Changing from one pattern of behavior to
K Mimicry another
J Narcissism i) Concentration on oneself and one's body
H Role transition j) Preoccupation with self
k) Observing and copying the behaviors of
a) A woman who has been pregnant more than others
once l) Pregnancy-related symptoms and behaviors
b) Mask of pregnancy experienced by some prospective fathers
c) Congested with blood in a part of the body

KEY CONCEPTS
[214] When does each of these markers in fundal height occur during pregnancy?
a) Uterus can first be palpated above the symphysis pubis. This typically occurs between 12 and 14
weeks of gestation. At this stage, the uterus rises out of the pelvis and can be felt by a healthcare
provider palpating the abdomen just above the symphysis pubis.
b) Fundus can be palpated midway between the symphysis pubis and umbilicus. This usually occurs
around 20 weeks of gestation. By this time, the uterus has grown enough to reach approximately
the midpoint between the symphysis pubis and the umbilicus.
c) Fundus is at the umbilicus level. This typically occurs around 20-22 weeks of gestation. At this
stage, the uterus has expanded further and reaches the level of the umbilicus.
 d) Fundus is at the xiphoid process. This usually occurs around 36 weeks of gestation. As the
pregnancy progresses, the uterus continues to rise, and by around 36 weeks, it typically reaches
the xiphoid process, which is the lowest part of the sternum.

[215] What is the cause of each of the following changes in the cervix during pregnancy? .
a) Chadwick's sign- Chadwick's sign is the bluish discoloration of the cervix, vagina, and labia
during pregnancy. It occurs due to increased blood flow and vascularity to the pelvic region. The
increased blood volume causes the tissues to take on a bluish color.
b) Goodell's sign- Goodell's sign refers to the softening of the cervix during pregnancy. It is caused
by increased vascularity and hormonal changes. The increased blood flow to the cervix leads to
increased water content, making the cervix feel softer and more pliable.
c) Mucous plug- The mucus plug is a protective barrier that forms in the cervical canal during
pregnancy. It is composed of thick mucus and serves to seal the cervix, protecting the developing
fetus from infections. The mucus plug is formed due to increased mucus production by the
cervical glands and hormonal changes.
d) Bloody show- Bloody show refers to the discharge of blood-tinged mucus from the vagina
towards the end of pregnancy or during labor. It is often a sign that the cervix is starting to dilate
and efface in preparation for labor. The bloody show occurs as a result of small blood vessels in
the cervix rupturing as the cervix changes and prepares for childbirth.

[216] What is the possible result of each of the following changes in the vagina during pregnancy?
a) Increase in vascularity- The increase in vascularity in the vagina during pregnancy leads to a
greater blood supply to the area. This increased blood flow can result in a heightened sensitivity
and engorgement of the vaginal tissues. It may contribute to a sense of fullness or increased
sensation during sexual activity.
b) Growth of connective tissue- The growth of connective tissue in the vagina during pregnancy
helps to support the expanding uterus and accommodate the growing fetus. This increased
connective tissue can contribute to the elasticity and flexibility of the vaginal walls. It helps the
vagina to stretch during childbirth, facilitating the passage of the baby through the birth canal.
c) Secretion of increased amounts of glycogen- The vaginal cells produce increased amounts of
glycogen during pregnancy. This glycogen-rich environment supports the growth of lactobacilli,
which are healthy bacteria in the vagina. These bacteria help to maintain an acidic pH balance,
which protects against the overgrowth of harmful bacteria. The increased glycogen secretion
supports a healthy vaginal environment during pregnancy.

[217] Why is progesterone essential in pregnancy? It supports the implantation and growth of the
embryo, maintains the uterine environment, modulates the immune system, and prepares the body for
breastfeeding.

[218] Progesterone is produced first by the corpus luteum and then by the placenta.

[219] Why does ovulation cease during pregnancy? Ovulation ceases during pregnancy due to the
hormonal changes that occur in a woman's body. The high levels of progesterone and hCG in the
body during pregnancy suppress the release of additional eggs from the ovaries.

[220] What breast changes occur during pregnancy? Breast enlargement, darkening of the areolas,
increased sensitivity and tenderness, vein prominence, Montgomery's tubercles and colostrum
production

[221] Describe changes in maternal heart sounds that may occur during pregnancy. When do the
changes in the heart sounds occur? Describe common changes in the heart sounds.
 During pregnancy, several changes can occur in maternal heart sounds. These changes are
primarily due to the physiological adaptations that take place in the cardiovascular system to
support the growing fetus. Here are some common changes in heart sounds that may occur during
pregnancy:

Physiological murmurs: It is not uncommon for women to develop innocent or functional heart
murmurs during pregnancy. These murmurs are harmless and occur due to increased blood flow
through the heart and blood vessels. Physiological murmurs are typically soft, systolic murmurs
and are considered normal in pregnancy.

Splitting of S2: The second heart sound (S2) is produced by the closure of the aortic and
pulmonic valves. In some pregnant women, the splitting of S2 may become more noticeable. This
occurs because of the increased blood volume and decreased systemic vascular resistance during
pregnancy, leading to a slight delay in the closure of the pulmonic valve compared to the aortic
valve.

Increased heart rate: During pregnancy, the heart rate typically increases to meet the increased
metabolic demands of the mother and fetus. This can lead to a faster heart rate, especially during
physical exertion or periods of increased activity.

Systolic ejection murmurs: In some cases, pregnant women may develop systolic ejection
murmurs, which are characterized by a blowing or whooshing sound during systole. These
murmurs can occur due to increased blood flow through the heart valves and blood vessels or
changes in blood flow patterns.

Cardiac hypertrophy: As the pregnancy progresses, the uterus enlarges and pushes against the
diaphragm. This can cause the heart to rotate and shift upward in the chest, leading to an increase
in cardiac size and displacement. The enlarged heart may result in changes in the location and
intensity of heart sounds.

The changes in heart sounds typically occur gradually throughout pregnancy and can vary among
individuals. Some women may not experience significant changes in heart sounds, while others
may notice more pronounced alterations. It's important to note that while most changes in heart
sounds during pregnancy are normal and physiological, any new or concerning symptoms should
be evaluated by a healthcare provider to rule out any underlying cardiac issues or complications.

[222] Complete the table to describe changes in the pregnant woman's blood. Consult a manual of
laboratory tests or medical-surgical text for nonpregnant values, if needed.
Component Nonpregnancy Level Pregnancy Level Change
Plasma volume 65 to 85 mL/kg 90–200 mL/kg ~ 45%
Red blood cell volume 4 and 6 million cells 3,750,000 cells per
per microliter of blood cubic millimeter ~ 30%
Leukocytes 4,500 to 11,000 6,000/cumm
neutrophils per ~ 36%
microliter
Fibrinogen 2.0 and 4.0 g/L 500 mg/dL. ~ 50%

[223] What is "supine hypotensive syndrome"? What signs and symptoms might a woman with this
syndrome display? What should the nurse do to prevent or relieve it? When the pregnant woman is
supine, the weight of the uterus partially occludes the vena cava and descending aorta. The occlusion.
 May impede return of blood from the lower extremities and reduce cardiac return output and blood
pressure. Symptoms include faintness, lightheadedness, dizziness, nausea and agitation. Some may
experience syncope. Turning to a lateral recumbent position alleviates the pressure on the blood
vessels and quickly corrects supine hypotension. Side-lying position prevents supine hypotension.
[224] Why does the pregnancy-induced change in fibrinogen levels have a protective effect yet also
increase the risk? Fibrinolytic activity, or the ability to break down clots, decreases during
pregnancy.Platelets may decrease slightly but remain within normal range. These changes offer some
protection from hemorrhage during childbirth, but also increase the risk of thrombus formation.

[225] What nasal changes are common during pregnancy? What causes them? The capillaries become
engorged, edema and hyperemia.This.Causes congestion, stuffiness, epistaxis, and deepening of the
voice. This is caused by estrogen increasing the vascularity of the mucous membranes of the Upper
respiratory tract.

[226] What two factors contribute to a woman's sense of dyspnea? Oxygen consumption increases by
approximately 20% in.Pregnancy hath is used by the uterus, fetus and placenta, and the rest is
consumed by breast tissue and increased cardiac, renal and respiratory demands. Hyperventilation
causes tidal volume to increase 30 to 40% Causing an increase in respiratory minute volume so the
partial pressure of carbon dioxide is lowered.

[227] Why are pregnant women more likely to develop gallstones? The gallbladder becomes hypotonic
and emptying time is prolonged, resulting in thicker bile and predisposing to the development of
gallstones.

[228] Why does a pregnant woman's bone mass remain stable, although the fetus requires calcium for
skeletal development? In the first trimester, absorption of calcium from the intestine is increased and
stored to meet the later needs of the fetus. The amount stored to the amount transferred is small in
comparison.

[229] What changes in carbohydrate metabolism and in the production, utilization, and breakdown of
insulin occur during pregnancy? Why do these changes occur? How does the woman's body normally
respond to these changes? Carbohydrate metabolism changes markedly during pregnancy as more
insulin is required as pregnancy progresses. Estrogen, progesterone, hCS, prolactin and cortisol cause
maternal tissue to be resistant to insulin. The mother then uses fat stores to meet energy needs.The
higher blood glucose levels make more glucose available for fetal energy needs and stimulates the
pancreas of a healthy woman to produce additional insulin.

[230] Describe edema that is expected during pregnancy and why it occurs. When should it be
reported? Because of hemodilution, A slight decrease occurs in coiled osmotic pressure, which favors
the development of edema during pregnancy. When the weight of the wrist compresses the veins of
the pelvis.It delays venous return, causing the veins of the legs to become distended and increased
venous pressure resulting in additional fluid shifts from the vascular compartment to interstitial
spaces. Edema of the feet and ankles at the end of a long day is normal as long as no other abnormal
signs are present.

[231] List the presumptive, probable, and positive indications of pregnancy. What is the difference
among the three classifications? Presumptive indications of pregnancy are: Amenorrhea, nausea and
vomiting, fatigue, urinary frequency, breast and skin changes, vaginal and cervical color changes
(Chadwick's sign), and quickening. Probable indications of pregnancy are: Abdominal enlargement,
cervical softening, ballottement, Braxton Hicks contractions, palpation of fetal outline, uterine
souffle, and pregnancy test. Positive indications of pregnancy are: Auscultation of fetal heart sounds,
 fetal movement felt by examiner, visualization of embryo or fetus. Presumptive.Indications are
subjective.Experiences and the least reliable indicators of pregnancy that can be caused by other
conditions. Probable are symptoms most found in pregnancies and more objective. Positive indicators
are confirmed pregnancies.

[232] List some reasons for a false-negative pregnancy test. False negatives can occur when pregnancy
test instructions are not followed properly. The pregnancy test is taken too early in gestation. If the
urine is too diluted. If the woman is taking certain drugs, such as diuretics.

[233] At what point in gestation is it possible to hear fetal heart sounds using Doppler? A Doppler may
detect heart motion and make an audible sound as early as nine weeks.

[234] Use Nagele's rule to calculate the estimated dates of delivery (EDDs) for each of these dates
representing last normal menstrual period dates.
a) February 4 = November 11
b) August 2 = May 9

[235] Why is a pregnancy risk assessment not a one-time evaluation? Risk factors change as pregnancy
progresses, and risk assessments must be updated throughout the pregnancy.

[236] What routine urine testing is performed during prenatal visits? The urine is tested for protein,
glucose and ketones. They may also check for nitrates. If the nitrates are positive then they may
conduct a Urine culture.

[237] How do each of the following differ when a woman has a multifetal pregnancy?
a) Uterine size The uterus may achieve a volume of 10 liters or more and weigh more than 9
kilograms.
b) Fetal movements Are more frequent.
c) Weight gain More weight gain occurs. Moms of multifetal pregnancies are usually advised to
gain 17 to 25 kg or more.

[238] Describe significant maternal changes that occur in a multifetal pregnancy.·

a) Blood volume Blood volume increases 500 milliliters over that needed for a single fetus.
b) Cardiac workload The increase of cardiac workload.May contribute to fatigue and activity
intolerance.
c) Respiratory workload Respiratory difficulty increases because the over distended uterus
causes greater elevation on the diaphragm.
d) Blood vessel compression The uterus.May cause more compression of the large vessels,
resulting in more pronounced and earlier supine hypotension.
e) Bowels Compression of the bowel makes constipation and hemorrhoids are a persistent
problem.

[239] What teaching is appropriate for each common discomfort of pregnancy?

a) Nausea and vomiting Eat dried crackers and toast and get out of bed slowly. Eat several
small meals. Drink fluids separately from meals. Avoid greasy, fatty foods. Try foods
containing ginger or peppermint, or combined salty and tart foods like potato chips and
lemonade. Take your prenatal vitamins at night. Rest more frequently. Ask your provider if
vitamin B6(Pyridoxine)would be helpful.
b) Heartburn Eat small meals. Don't smoke. Avoid caffeinated or carbonated beverages. Try
chewing gum. Walk or sit upright after meals. Do not eat or drink just before bedtime.
Wear loose fitting clothes. Take deep breaths and sip water. Use antacids as recommended
 by provider.
c) Backache Maintain correct posture.Do not gain excess weight.Avoid high heeled shoes.Squat
rather than bend at waist.Do not pick up heavy objects.When sitting, use support
devices .Perform exercises to strengthen back.
d) Urinary frequency Decrease fluids in the evening, but drink adequate amounts in the
day.Avoid caffeine.Perform Kegel exercises.
e) Varicosities Avoid constricting clothing and crossing legs at the knees.Rest frequently with
legs elevated.Where support hose or elastic stockings.If working in one position.Walk
around a few minutes at least every couple hours.
f) Hemorrhoids Avoid Constipation to prevent straining.Drink plenty of water. Eat foods rich
in fiber.To relieve existing ones, take frequent tempid baths. Apply cool witch Hazel
compresses.Lie on your side with hips elevated.
g) Constipation Use laxativesAs ordered by provider.Drink plenty of fluids.Eat food high in
fiber.Restrict cheese consumption.Reduce intakes of sweets.Exercise.Establish a pattern.Use
a foot rest when voiding.
h) Leg cramps Elevate the legs often.To improve circulation. Extend the affected leg by keeping
the knee straight.Avoid excessive amounts of food high in phosphorus.

[240] What should the pregnant woman be taught about the following practices during pregnancy?
How would you explain this to a woman if you were the nurse?
a) Over-the-counter drugs
b) Tobacco
c) Illegal drugs
d) Hot tubs and saunas
e) Douching
f) Exercise
g) Use of a seatbelt

[241] List the typical maternal responses for each trimester of pregnancy.
a) First trimester Uncertainty.Ambivalence.The self as primary focus.
b) Second trimester The fetus as primary focus.Narcissism and introversion.Changes in
sexuality.Body image.
c) Third trimester Vulnerability.Increasing dependence.Preparation for birth.

[242] What changes occur that make the fetus seem real to the pregnant woman?
Increase in uterine size, weight gain, breast changes, fetal movement (quickening).
[243] How might sexual interest and activity change during pregnancy? What factors may increase or
decrease interest in either partner of the couple?
Sexual interest may be heightened or reduced. The woman may be more responsive because
pelvic vasocongestion heightens the sensitivity and lubricates the vaginal area. Fear of miscarriage,
harming the fetus, or causing discomfort may suppress sexual desire in either partner. The woman
may feel less attractive, or her partner may find her less attractive at this time.
[244] How does the woman's perception of the baby change during pregnancy?
a) First trimester- The fetus seems vague and unreal rather than feeling like a baby to her
b) Second trimester- Perceives the fetus as real and needing her protection, growing sense of the
fetus as a separate person
c) Third trimester- Wants to see her baby on the outside and as a separate being

[245] What is the significance of quickening in the woman's developing relationship with her fetus?
It makes the fetus seem much more like a separate being rather than a part of the woman’s
body.
[246] Why might grief have a place during a desired and normal pregnancy?
Grief may be caused by feelings of giving up life as a carefree woman and loss of
spontaneity to go to places and do things.
[247] Describe the four maternal tasks of pregnancy, according to Rubin.
1. Seeking safe passage for herself and the baby
2. Securing acceptance of herself and the baby
3. Learning to give of herself
4. Developing an attachment and interconnection to the unknown child
[248] Describe the three developmental processes that the expectant father goes through during a
pregnancy.
1. Grappling with the reality of pregnancy and a new child
2. Struggling for recognition as a parent
3. Desire to be seen as relevant to the childbearing process
[249] Describe ways to ease the adaptation of siblings to the birth of an infant.
a) Toddlers Make any changes in sleeping areas before the infant arrives; may feel displaced;
prepare others for feelings of resentment and jealousy
b) Preschoolers May look forward to brother or sister and how the baby is born and grows but have
little understanding of how small and helpless the infant will be; need assurance of parent’s love
c) School-age children They enjoy preparing for the baby, and want information about growth and
changes in the fetus; enjoy time alone with parents
d) Adolescents May be embarrassed about their parents’ obvious sexuality, preoccupied with their
own issues, and/or look forward to the infant; involve them to the extent for which they are
comfortable.

[250] How may each of these factors influence a woman's psychosocial adaptation to pregnancy?
a) Young age Has difficulty putting aside her own desires for the well-being of an infant; must give
of herself before developmentally prepared to do so
b) Absence of a partner may be poor and have late prenatal care; must enlist others to provide
support that a partner would provide
c) Multiparity May grieve for the exclusive relationship with the first child; concern about having
enough time and energy to spread around; concern about the acceptance of new infant by another
child or children

[251] What do each of these factors have to do with a woman's choice to take childbirth classes?
a) Income Low-income women may not be able to pay for these classes. They may enter prenatal
care late or have none and may miss opportunities even for free classes.
b) Desire to participate Some want education so that they can fully participate in all decisions
related to childbearing
c) Fear Some want to obtain the skills to help them cope with the pain and demands of birth.

[252] List three important precautions for exercise classes during pregnancy.
Do warm up exercises
Ensure low-impact activities
Avoid excessive heart rate elevation

CLINICAL JUDGMENT
[253] The nurse performs an assessment of 38-year-old multiparous client. This is her first prenatal
visit. Today's date is August 15, 2021. Her fundal height is at the level of the umbilicus. She denies
any major complaints and states that her health has been good. The following information is
 documented by the nurse in the electronic health record.
● Health History
o Allergies: None
o Current Medications: Prenatal vitamin daily
o Past Health History: Appendectomy age 16
● Obstetric History
o LMP: 4/3/2021
o See Table below
Date of Delivery Weeks of Gestation Sex Type of Delivery and Any Complications
7/31/2019 40 Male SVD and none
5/15/2018 10 Unknown Spontaneous AB
6/15/2016 38 Female SYD and none (TOLAC)
2/3/2014 35 Female x 2 C/S and none
(Twins)
Based on the client’s obstetric history from the table above, choose the most likely options for the
information missing from the statements below by choosing from the list provided options.

The client's gravida is __5__ and her parity is __3__. The number of term deliveries is __2__, the number
of preterm deliveries is __1__, the number of aborted deliveries (spontaneous, missed, or therapeutic) is
__1__ and the number of living children is __4__. The current gestational age of her baby is __20
weeks__. The client's estimated date of delivery is __January 10, 2022__.
Options for 1, 2, 3 Options for 4, 5, 6, Options for 7 Options for 8
2 1 32 weeks March 7, 2022
3 1 22 weeks February 6, 2022
4 3 20 weeks December 7, 2021
5 4 18 weeks January 10, 2022

Choose the correct answer.

[254] A pregnant woman expects to give birth to her first baby in approximately 1 week. She asks the
nurse whether she has a bladder infection because she urinates so much, although urination causes no
discomfort. The nurse should explain to her that:
a) urinary tract infections are most common just before birth, so she should have a urine specimen
tested.
b) her fetus is probably lower in her pelvis, putting more pressure on her bladder.
c) limiting her fluid can reduce the number of times she must interrupt her activity to urinate.
d) the fetal growth has probably stopped and she should expect to start labor in a few days.

[255] A woman having physiologic anemia of pregnancy has hemoglobin and hematocrit levels of at
least:
a) l0 g/dL and 30%.
b) 10.5 g/dL and 32%.
c) 11 g/dL and 35%.
d) 12 g/dL and 38%.

[256] Slight respiratory alkalosis during pregnancy enhances:

a) the growth of the fetal arteries within the placenta.
 b) the decrease in systolic and diastolic blood pressures.
c) maternal metabolism of food and nutrients.
d) transfer of fetal carbon dioxide to the maternal blood.

[257] A pregnant woman is prone to urinary tract infection primarily because: urine stasis allows
additional time for bacteria to multiply
[258] large volume of fetal wastes must be excreted by her kidneys.
[259] urine stasis allows additional time for bacteria to multiply.
[260] the volume of urine excreted is and its specific gravity is high.
[261] reduced blood flow to the urinary tract allows waste to accumulate.

[262] A pregnant woman complains that both of her thumbs hurt at times. Neither thumb is inflamed or
discolored. The nurse should explain to the woman that:
a) she probably injured her hand and does not recall doing so. .
b) an undiagnosed fracture may have improperly healed.
c) osteoarthritis often has its onset during pregnancy.
d) increased tissue fluid is causing nerve compression.

[263] A pregnant woman has a blood glucose screening at 26 weeks of gestation. The result is 128
mg/dL. The nurse should expect that:
a) no additional glucose testing will be needed.
b) insulin injections will be needed by 30 weeks of gestation.
c) oral drugs may be prescribed to lower her glucose level.
d) more testing is needed to determine additional therapy.

[264] A woman who is 12 weeks pregnant begins wearing maternity clothes. This is most likely an
example of:
a) introversion.
b) mimicry.
c) narcissism.
d) fantasy.

[265] Choose the maternal behavior that best describes role playing during pregnancy.
a) The woman shifts from saying, "I am pregnant" to "I am having a baby."
b) The woman begins ca11ing her fetus by a name rather than "it."
c) The woman tries to care for infants while an experienced mother watches.
d) The woman becomes less absorbed in her own needs and focuses on the fetus,

[266] The nurse can best help a man assume his role as a parent by:
a) encouraging him to ask questions about his partners pregnancy.
b) referring him to prenatal discussion groups for expectant fathers.
c) advising the woman to limit discussions of her symptoms during early pregnancy.
d) enrolling him in childbirth classes to actively involve him in the birth process.

[267] Choose the most likely reaction of an 8-year-old to his mother's pregnancy.
a) Embarrassment or shame at his mother's appearance
b) Inability to sense the reality of the infant
c) Desire to role play his big-brother status
d) Interest in learning about the developing baby
[268] The nurse is teaching a Laotian woman about self care during pregnancy. The nurse can best
determine whether she learned the information by:
a) asking the woman to indicate what teaching she did and did not understand.
b) observing for the woman's eye contact with the nurse during teaching.
c) recognizing that nodding while being taught indi cates understanding.
d) having the woman restate the information that is taught.

[269] The primary benefit of a preconception class is to:

a) reduce the risk of having a baby with a birth defect.
b) begin the pregnancy in an optimal nutritional state.
c) limit the number of unplanned pregnancies in the community.
d) encourage the couple to have their baby at that facility.

[270] The primary benefit of perinatal education is to help:

a) reduce the likelihood that the parents will have problems with their infant.
b) women have a satisfying, medication-free childbirth.
c) parents become active in health maintenance during pregnancy and birth.
d) enhance the chance that the prospective parents will return to a hospital.

Chapter 14: Nutrition for Childbearing

[271] Match the term with the correct definition.

__d__ Gynecologic age per 100 calories
__e__ Heme iron d) Number of years since menarche
__b__ Kilocalorie e) Iron form most usable by the body; obtained
_i___ Lactovegetarian from meat, poultry, or fish.
_k___ Lacto-ovovegetarian f) Iron form less usable by the body; obtained
__j__ Ovovegetarian from plants and fortified foods
__a__ Pica g) One who eats no animal products
__f__ Nonheme iron h) One whose diet is primarily plant foods and
__c__ Nutrient density who avoids animal foods
__h__ Vegetarian i) Vegetarian who includes milk products in
__g__ Vegan his or her diet
j) Vegetarian who includes eggs in his or her
a) Ingestion of a nonfood substance diet
b) Measure of the energy value of foods k) Vegetarian who includes milk and eggs in
c) Quality of proteins, vitamins, and minerals his or her diet

KEY CONCEPTS
[272] List four major consequences associated with an inadequate prenatal weight gain.
Insufficient weight gain during pregnancy has been associated with low birth weight (less than 2500 g, or
5.5 lb), small-for-gestational age infants, preterm birth, and failure to initiate breastfeeding.

[273] List six major consequences associated with an excessive prenatal weight gain.
Increased birth weight (macrosomia), cesarean birth, postpartum weight retention, low Apgar score,
hypoglycemia, and overweight in children

[274] List the suggested pregnancy weight gains for each category.
a) Normal pre-pregnancy body mass index (BMI) 18.5 to 24.9- 11.5-16 kg
b) Pre-pregnancy BMI <18.5- 12.5-18 kg
 c) Pre-pregnancy BMI 25 to 29.9- 7-11.5 kg
d) Pre-pregnancy BMI >30- 5-9 kg

[275] A general guideline for pregnancy weight gain is 0.5 kg to 2 kg, (1.1 to 4.4 pounds) during the
first trimester and 0.35 to 0.5 kg ( 0.8 to 1 lb) per week thereafter.

[276] List the kilocalorie content for the following food types.
a) Carbohydrates 4 /g
b) Proteins 4 /g
c) Fats 9 /g

[277] During the first trimester, an increase in kcal/day is not needed. During the second trimester, the
woman should take in approximately 340 kcal/day more than her usual intake. During the third
trimester, an increase in 452 kcal/day more than her usual intake is needed.

[278] Daily pre-pregnancy protein needs average 46 g. The amount of protein needed during pregnancy
is 25 g /day.

[279] Name the four fat-soluble vitamins.

fat-soluble vitamins (A, D, E, and K) are stored in the liver
too much vitamin A can cause fetal defects

[280] List some high-calcium foods other than dairy foods.

Calcium sources equivalent to 1 cup of milk:
• ¾ c yogurt, fruit, low fat
• 1½ oz cheddar cheese
• 1¼ c cottage cheese
• 4 oz almonds
• 3¾ c dried pinto beans, cooked
• 2 c cereal, Cheerios
• 3 packets instant oatmeal
• 3 English muffins
• 1 c collard greens, cooked
• 5 oz canned salmon with bones
• 3 oz canned sardines
• ½ block tofu made with calcium sulfate and magnesium chloride

[281] Why is a routine vitamin-mineral capsule supplementation risky? Because they may not be
formulated to meet your individual needs and could be harmful to you and your baby.

[282] The recommended fluid intake during pregnancy is 8 to 10 cups daily. Which fluids should be
limited? Fluids low in nutrients should be limited because they are filling and replace other, more
nutritious, foods and drinks.

[283] What is the recommended number of servings from each food group for pregnant women?
a) Whole grains - 7–9 oz
b) Vegetables - 3–3½ c
c) fruits - 2 c
d) Dairy foods - 3 c
e) Protein foods - 6–6½ oz
 f) Fats, oils, concentrated sugars - 6 to 8 teaspoons

[284] Describe the eligibility aspects of the WIC (Special Supplemental Nutrition Program for Women,
Infants, and Children) program. Eligibility is based on an income of 185% of the federal poverty level
or less. Women are eligible throughout pregnancy and for 6 months after birth if formula feeding or 1
year if breastfeeding. Children at risk for poor nutrition may be eligible until 5 years of age.

[285] Which nutrients are usually lacking in the diets of adolescents? Vitamins A, B6, and C, folic acid,
calcium, iron, zinc, and magnesium.

[286] Describe the nursing approaches that enhance the likelihood that an adolescent will follow a
nutritional diet during pregnancy. It is essential to establish an accepting, relaxed atmosphere and
show willingness to listen to the teenager’s concerns. Her lifestyle, pattern of eating, and food likes
and dislikes should be explored to determine if changes are needed in her diet. The nurse should keep
suggestions to a minimum, focusing on only those changes that are most important. Asking for the
adolescent’s input increases the likelihood that she will follow suggestions.

[287] Explain how a vegetarian woman can meet the needs of pregnancy for each nutrient listed.
a) Protein - grains (wheat, rice, corn) and legumes (garbanzo, navy, kidney, pinto or soybeans; peas;
and peanuts). Tofu, made from soybeans, which provides protein as well as calcium and iron.
Meat analogs that have a texture similar to meat but are made from vegetable protein are
available.
b) Calcium - Calcium-fortified juice or soy products, such as soy milk or tofu, calcium supplements.
Vitamin D supplementation is especially important if the woman drinks no milk and has little
exposure to sunlight. Soy milks may be enriched with vitamin D.
c) Vitamin B12 - fortified foods such as cereal and some soy products or take B12 supplements.

[288] List a nursing teaching that helps a pregnant woman manage nausea and vomiting.

A nursing teaching that helps a pregnant patient manage nausea and vomiting is to consume high protein
snacks when waking up or before bed. In addition eating small frequent meals that are low in fat but high
in protein and carbohydrates. Along with plenty of fluids. Vitamin B6 and ginger can also be taken to
help with morning sickness/ nausea and vomiting.

[289] What nutritional problems may the multipara have?

Some nutritional problems of the multipara patient are iron deficiency/ anemia, hypoproteinemia,
hypocalcemia, folic acid deficiency, and dehydration.

[290] What additional nutritional needs does the woman with a multifetal pregnancy have?
Additional nutritional needs that the women with a multifetal pregnancy are iron, folic acid,
vitamin D, and vitamin B12.

[291] What nutritional needs do women in each of these situations have?

 a) Substance abuse- increased/ decreased intake of calories, malnutrition, decreased protein/ fruits/
vegetable depleting appropriate nutrients to be received.
b) Smoking- smoking increases the maternal metabolic rate and decreases appetite which may result
in lower weight gain. Smoking also decreases the availability of some vitamins and minerals.
c) Alcohol abuse- Alcohol interferes with the absorption and use of vitamin B12, folic acid, and
magnesium, causing nutrient stores to be depleted. Alcohol also takes the place of food in the
diet.

[292] How may each of these drugs interfere with nutrition intake during pregnancy?
a) Marijuana- increased intake of refined carbohydrates.
b) Heroin- metabolic disruption, increased intake of refined carbohydrates, blood sugar disorder
causing malnourishment
c) Cocaine- Cocaine causes loss of appetite leading to the pregnant patient not getting the sufficient
nutritional intake needed causing malnutrition and weight loss.
d) Amphetamine- decreased/ no weight gain due to decreased appetite. Also causes insomnia that
may cause risks to the fetus/ during pregnancy.

[293] What problems may occur in each of these lactating mothers?

a) Dieter- Milk volume is usually adequate even if the mothers diet is less than optimal but the
volume may be reduced and maternal stores of nutrients will be depleted with a very low caloric
intake.
b) Adolescent- Adolescent diet is low in vitamins A, B6, C, folic acid, calcium, iron, zinc, and
magnesium. If weight loss is a major focus it can cause restriction of calories. Since the infant
requires a steady supply of nutrients the mothers nutrition may be used if intake is not sufficient
to meet fetal needs. The combination of poor intake and unreliable supplementation may delete
nutrient stores and general nutritional intake.
c) Vegan- Their diet may be lacking inadequate calcium, iron, zinc, riboflavin, and vitamin D, B6,
and B12. Vegan diets may be low in calories and fat and may not meet the energy needs of
pregnancy. The diet is high in fiber and may cause feelings of fullness before enough calories are
eaten.
d) One who avoids dairy products-The calcium content of breast milk is not affected by maternal
intake. Less calcium is excreted in the urine during lactation. women who don't eat dairy products
should obtain calcium from other sources or take a calcium supplement.

[294] What are the recommendations for each of these substances during lactation?
a) Alcohol: An occasional single alcoholic beverage may not be harmful, but larger amounts may
interfere with milk ejection reflex and be harmful to the infant. Wait 2 hours before nursing.
b) Caffeine: limit coffee to one to two cups a day. caffeine in excessive amounts may make the
infant irritable.
c) Fluid intake: Eight to ten glasses of fluids to relieve thirst that often increases in the early
breastfeeding period.

CLINICAL JUDGMENT
[295] Carmen is a 23-year-old Latina who is pregnant with her third baby. She is being seen for the first
time in the clinic. Her other two children are 1 and 2-years-old. Her last menstrual period was 15
weeks ago. She is 63 inches tall and weighs 152 pounds, 15 pounds more than her prepregnant
weight. Her hemoglobin level is l0.5 g/dL. She says "can't drink milk" but prefers to drink colas.
Carmen is married, and her husband works as a gardener.
Highlight the information that requires follow-up by the nurse. Provide rationale for the
highlighted items.
 - “She is being seen for the first time in the clinic. Her other two children are 1 and 2 years old”-
The nurse can ask if she has had prior prenatal care/ visits at a different clinic, were there any
complications with her prior pregnancies/ deliveries, the method of delivery for her two children,
and past medical history. Finding out Carmen 's full pregnancy history is important since she’s
multigravida she is at higher risk for complications.
- “Last menstrual period was 15 weeks ago”- The nurse can ask when the first day her menstrual
cycle began to be able to calculate the expected date of delivery.
- “...15 pounds more than her prepregnant weight.”- The nurse can ask what her nutritional intake
is, meals eaten regularly/ often, if cravings are present, daily meal schedule, and
- “Her hemoglobin level is 10.5 g/dL.”- The nurse can ask the patient if she has been taking any
prenatal vitamins, folic acid, iron, vitamin C, Vitamin B6, calcium, etc. Carmen hemoglobin is
10.5 g/dL which is low.
- “She says ‘cant drink milk’ but prefers to drink colas.”- The nurse can ask if the patient has
allergies to milk such as being lactose intolerant and what other fluids she is consuming and how
much. Sixteen cups of water/ fluid should be consumed a day. Making sure the patient isn't
dehydrated causing malnutrition.
- “... her husband works as a gardner.”- The nurse can ask if her partner leaves his work clothes in
his car or at work since gardening can increase the chance of getting toxoplasmosis.

Choose the correct answer.

[296] The recommended total weight gain during pregnancy for a 15-year-old of normal weight for
height should be approximately:
a) 12 pounds.
b) 20 pounds.
c) 35 pounds.
d) 45 pounds.

[297] When teaching an adolescent about nutrition during pregnancy, the nursing approach should:
a) focus on the girl's responsibility to her fetus.
b) provide as many choices as possible from nutritious foods.
c) ask the girl to limit snacking and fast foods.
d) explain how a good pregnancy diet will promote her health.

[298] Poor weight gain during early pregnancy is associated with:

a) pregnancy-induced hypertension.
b) small-for-gestational-age infants.
c) preterm labor and birth.
d) risk for postpartum hemorrhage.

[299] To reduce the incidence of neural tube defects such as spina bifida, women of childbearing age
are recommended to consume:
a) at least 0.4mg folic acid per day in foods and supplements. .
b) 300 extra calories near the expected conception date.
c) 60mg of supplemental iron, in addition to high-iron foods.
d) two added servings of foods high in vitamin C.

[300] Choose the correct nursing teaching about a woman's iron supplement during pregnancy.
a) Take the iron supplement 30 minutes before the first food of the day.
b) Taking the iron supplement with dairy foods will reduce the gastric side effects.
c) Stools are somewhat loose and are lighter brown than usual.
 d) A food high in vitamin C may enhance the absorption of iron.

[301] A calcium supplement is best taken:

a) with high-iron foods.
b) at bedtime.
c) with meals.
d) upon arising.

[302] The main risk to a woman who practices pica during pregnancy is: . .
a) inadequate intake of essential nutrients.
b) rapid absorption of nutrients such as iron.
c) reduced fluid intake because of ice consumption.
d) nonacceptance of the practice by caregivers.

[303] Choose the correct nursing approach regarding caffeine use during pregnancy.
a) Teach that caffeine has not been shown to be a risk.
b) Limit the total intake of caffeine-containing drinks to four daily.
c) Discuss the sources of caffeine in addition to coffee and tea.
d) Drink one additional glass of plain water for each caffeine-containing drink.

[304] A non-breastfeeding woman is anxious to lose weight after birth. Which nursing education is
most appropriate?
a) She may immediately begin dieting because she is not breastfeeding.
b) She should consume a minimum of 1800 calories each day to maintain energy.
c) She should take her prenatal vitamin-mineral supplement while dieting.
d) She should wait at least 3 weeks before beginning a diet.

Chapter 15: Prenatal Diagnostic Testing

[305] Match the term with the correct definition.

_H___ Alpha-fetoprotein (APP) structures
__G__ Amniocentesis b) Substance secreted by mature fetal lungs
__D__ Biophysical profile c) Congenital defect of the spinal cord
__E__ Chorionic villus sampling (CVS) d) Method of evaluating fetal well-being
__B__ Lecithin/sphingomyelin ratio e) Tissue obtained from the fetal side of the
__C__ Neural tube defect developing placenta
__F__ Surfactant f) Ratio used to determine fetal lung maturity
__A__ Ultrasonography g) Withdrawing amniotic fluid for laboratory
examination
a) Imaging technique that uses high-frequency h) Fetal proteins used to screen for specific
sound waves to visualize internal body abnormalities

KEY CONCEPTS
[306] List typical purposes for an ultrasound examination during the:
a) First trimester:
• Determining the presence and location (intrauterine or elsewhere) of pregnancy

• Detecting multifetal gestations

 • Estimating gestational age

• Confirming fetal viability

• Identifying the need for follow-up testing

• Identifying ultrasound characteristics that suggest fetal abnormality, such as chromosome defects

• As an adjunct for transcervical or transabdominal chorionic villus sampling (CVS)

b) Second and third trimesters:

• Confirmation of fetal viability

• Evaluation of fetal anatomy

• Estimation of gestational age

• Assessment of fetal growth progress over a series of scans

• Comparison of fetal growth in multifetal gestation

• Evaluation of amniotic fluid volume (see also “Biophysical Profile,” p. 288)

• Determination of the relative locations of the placenta and umbilical cord and the insertion of the
cord into the fetal abdomen

• Determination of fetal presentation

• Guiding needle placement for procedures such as amniocentesis and percutaneous umbilical blood
sampling (PUBS)

[307] In which type of ultrasound examination is a full bladder needed, transvaginal or transabdominal?
What is the reason?

With the transabdominal ultrasound a full bladder is needed to displace the intestines and elevate
the uterus for better visualization.
[308] Under what circumstances is an accurate gestational age especially important? How is it assessed
by ultrasonography? When is the gestational age determination most accurate?
An accurate gestational age is important when intrauterine growth is restricted or the
delivery date is uncertain. It is assessed by a transabdominal ultrasound and is used to
identify structures of the fetus. The gestational age is most accurate during the last half of
pregnancy but not after 32 weeks.

[309] What conditions are suggested by alpha-fetoprotein levels that are:

a) Low: chromosomal anomalies, such as trisomy 21 (Down syndrome)
b) High: anencephly or failure of the embryonic neural tube or anterior body wall to close properly

[310] What is multiple-marker screening and what is its purpose? What follow-up tests may be needed?
Multiple marker screening is used to detect chromosomal abnormalities.
[311] Chorionic villus sampling (CVS) is done as early as __10____ weeks of pregnancy.
[312] List four risks of CVS.
Heavy Bleeding, Passage of Amniotic fluid, and Miscarriage.
[313] List the purpose for amniocentesis during the:
a) Second trimester:examine fetal cells present in amniotic fluid to identify chromosomal or
biochemical abnormalities
b) Third trimester: determine fetal lung maturity or to evaluate fetal hemolytic disease that is often
caused by Rh incompatibility.

[314] What lecithin/sphingomyelin (LIS) ratio suggests fetal lung maturity? In what maternal disorder
may this ratio not be associated with fetal lung maturity?
2:1 ratio suggests fetal lung maturity. Maternal disorder of diabetes may not suggest fetal lung
maturity.

[315] What is the purpose of testing phosphatidylglycerol (PG) and phosphatidylinositol (PI) in the
amniotic fluid?
To test for lecithin as these boost the properties of lecithin

[316] Mid-trimester amniocentesis results are known in approximately 2 or more weeks.

[317] What is the purpose of a vibroacoustic stimulation test (VST)?

Use of sound to confirm whether NST findings are reassuring and shorten the time to obtain
quality NST data

[318] The basic principle of the contraction stress test is to observe the response of the fetal
oxygenation to the stress of contractions through oxytocin infusion or nipple stimulation.

[319] What two methods are used to cause uterine contractions when conducting a contraction stress
test?
Breast self- stimulation and IV infusion of low-dose oxytocin
[320] Describe the possible results and implications of a contraction stress test.
-Negative (reassuring): no late or significant variable decelerations
-Positive (nonreassuring): Late decelerations follow 50% or more of contractions
-Equivocal-suspicious: Intermittent late or significant variable decelerations
-Equivocal-tachysystole: FHR decelerations occur in presence of excessive contractions (more
frequent than every 2 min or lasting longer than 90 sec)
-Unsatisfactory: Fewer than 3 contractions within 10 min or tracing could not be interpreted
[321] The biophysical profile assesses which five fetal parameters?
NST (non stress test), fetal breathing movements, gross fetal movements (large trunk motions),
fetal tone (small or fine body motions), and amniotic fluid volume
[322] What is the significance of oligohydramnios?
Indicates prolonged fetal hypoxia and strongly suggests fetal compromise
CLINICAL JUDGMENT
[323] A 40-year-old client is in the prenatal clinic today for a nonstress test at 32 weeks gestation.
Health history data show that the client has Type 1 diabetes. For each health assessment finding
below, use an "X" to indicate whether it is expected or requires nursing follow-up.
Assessment Findings Expected Requires Nursing Follow up
Temperature 98.6F/37C x
Blood sugar 107 mg/dl x
On non-stress test (NST), fetal x
heart rate baseline 155
 On NST, variable decelerations x
are present
Client reports decreased fetal x
movement
On NST, after 40 minutes, no x
accelerations are present

Choose the correct answer.

[324] The fetal heartbeat should be visible on ultrasound by the:
a) 8th week following the last menstrual period.
b) 12th week following the last menstrual period.
c) 20th week following the last menstrual period.
d) 22nd week following the last menstrual period.

[325] Fewer fetal movements than expected suggest:

a) intrauterine fetal growth retardation.
b) inaccurate gestational age dating.
c) rapid intrauterine fetal maturation.
d) reduced placental perfusion with fetal hypoxia.

[326] Choose the appropriate patient teaching related to maternal serum alpha-fetoprotein (MSAFP)
analysis.
a) Abnormal MSAFP levels should be followed by more specific tests.
b) High MSAFP levels are usually associated with chromosome abnormalities.
c) Having MSAFP testing will eliminate the need to perform an ultrasound examination.
d) The initial MSAFP testing will be performed at 12 weeks of gestation.

[327] Choose the correct patient teaching following amniocentesis.

a) Drink one to two quarts of clear fluid to replace fluid taken in the procedure.
b) Resume all normal activities when desired.
c) Report persistent contractions, vaginal bleeding, or fluid leakage.
d) Eat a diet with increased iron content for 2 days after amniocentesis.

[328] A woman who is assessing fetal movements each day should notify her healthcare provider if
a) more than six movements are felt during a 30- to 60-minute period.
b) she perceives fewer than 10 fetal movements within 12 hours
c) the movement pattern changes very little from day to day
d) fetal movements are more frequent during the evening than in the morning.

Chapter 16: Giving Birth

[329] Match the term with the correct definition.

__G__ Amniotomy __A__ Station
__E__ Attitude
__H__ Crowning
__B__ EDD a) Measurement of the descent of the fetal
__C__ Engagement presenting part
__D__ Molding b) Estimated date of delivery
__F__ Nuchal cord c) Descent of widest fetal presenting part to
 zero station f) Umbilical cord around the fetal neck
d) Change in the shape of the fetal head during g) Artificial rupture of the amniotic sac, or
birth membranes
e) Relationship of fetal body parts to one h) Appearance of the fetal presenting part at
another the vaginal opening

KEY CONCEPTS
[330] Explain why each characteristic of uterine contractions is important during birth.
a) Coordination- As the woman approaches full term, contractions become organized and gradually
assume a regular pattern of increasing frequency, duration, and intensity during labor.
Coordinated labor contractions begin in the uterine fundus and spread downward toward the
cervix to propel the fetus through the pelvis.
b) Involuntary- Uterine contractions are not under conscious control as the skeletal muscles the
mother cannot cause labor to stop or start by conscious Effort. Walking or other activities may
stimulate existing labor contractions. Anxiety and excessive stress can diminish them.
c) Intermittent- Labor contractions are intermittent rather than to stand, allowing relaxation of the
uterine smooth muscles and reception of blood flow to and from the placenta to permit gas,
nutrients and waste exchange for the fetus.

[331] Describe the differences in how the upper and the lower uterus contract during labor. Why is it
important that the upper and lower parts of the uterus have different contraction characteristics? The
upper 2/3 of the uterus contracts actively to push the fetus down. The lower 1/3 of the uterus remains
less active, allowing downward passage of the fetus. The net effort of labor contractions is enhanced
because the downward push from the upper uterus is accompanied by reduce resistance to fetal
dissent in the lower uterus.

[332] Why should the nurse regularly check the woman's bladder during labor? The nurse should
regularly check the woman’s bladder during labor because a full bladder can also inhibit fetal descent
because it occupies space in the pelvis. Also the decrease in sensing a full bladder due to Intense
contractions or the effects of regional pain management such as epidural, the woman may be unaware
that her bladder is full.

[333] What maternal and fetal conditions may reduce fetal tolerance for the intermittent interruption in
placental blood flow that occurs during contractions? Maternal conditions such as hypotensive and
hypertensive, fever, excessive contractions, or fetal conditions that compress the umbilical cord can
compromise fetal oxygenation.

[334] What are the changes in fetal lung fluid during pregnancy,during labor, and after birth? The
changes in fetal lung fluid during pregnancy, during labor, and after birth would be the lungs are
filled with fluid while in the amino sack during labor the babies’ thoracic cavity is being squeezed
through the mothers pelvic bone moving the fluid around as baby takes its first breaths, and after birth
suction secretions from the infant mouth and nose with the bulb syringe as needed to get rid of left
over fluid

[335] What are the two powers of labor? When during labor do they come into play? Two powers of
labor would be Uterine contractions and maternal bearing down efforts. These come in to play when
active labor is occurring.
[336] Why are the sutures and fontanels of the fetal head important during birth? The sutures in the
different shapes of the fontanelles provide landmarks to determine fetal position and head flexion
during vaginal examination.

[337] Describe the most common variations in:

a) Fetal lie- The orientation of the long axis of the fetus to the long axis of the woman.
b) Fetal attitude-Relationship of fetal body parts to one another.
c) Fetal presentation-The fetal part that enters the pelvis first.

[338] Draw the three variations of a breech presentation. Which one is the most common?

Frank breech is the most common presentation.

[339] What fetal anatomic reference point is used for each presentation or position?
a) Vertex-The fetal head is fully flexed, the most common presentation
b) Face-The head is fully extended and the fetal occipit is near the fetal spine
c) Breech-The fetal buttocks or feet enter the pelvis first

[340] How can nursing measures help increase a woman's sense of control during labor?
They promote relaxation and the ability to work with her body’s efforts rather than working against the
natural forces

[341] How do each of these factors affect the onset of labor?

a) Fetal hormone production Increased fetal glucocorticoid and androgens
reduce placental progesterone production (which relaxes the uterus) and increase prostaglandin
pro-duction (which stimulates the uterus).
b) Change in the maternal progesterone and estrogen relationship
Higher estrogen levels make the uterus more sen-sitive to substances that stimulate it to contract, while
lower progesterone levels allow it to be more easily stimulate

[342] Describe the common premonitory signs of labor. Are there differences between a nullipara anda
parous woman?
Braxton Hicks contractions: irregular, mild contrac-tions intensify near term; more noticeable in parous
women; lightening: descent of the fetus toward the pelvic inlet increases pressure on bladder but allows
easier breathing; more noticeable in nulliparas; increased vaginal secretions with the congestion of the
vaginal mucosa caused by fetal pressure; bloody show: a mixture of cervical mucus and blood as the
mucus plug is released; seen earlier and in greater quantity in nulliparas; energy spurt; weight loss of one
to three pounds.

[343] Describe each mechanism of labor and its significance. Refer to Figure 16-12 to complete this
exercise
a) Descent: of the fetal presenting part through the true pelvis.
b) Engagement: of the fetal presenting part as its widest diameter reaches the level of the ischial
spines of the mother’s pelvis.
 c) Flexion: of the fetal head so that the smallest head diameter passes through the pelvis.
d) Internal rotation: to allow the largest fetal head diameter to match the largest maternal pelvic
diameter.
e) Extension: of the fetal head as it passes beneath the mother’s symphysis pubis.
f) External rotation: of the fetal head to allow the shoulders to rotate internally to fit the mother’s
pelvis.
g) Expulsion: of the fetal shoulders and fetal body.

[344] Why must the fetal head and shoulders undergo rotation within the pelvis?
After the fetal head is born, the fetal shoulders are transverse (crosswise) in the pelvis and must rotate to
pass under the pubic arch.
[345] What are the three labor phases in stage one? What cervical dilation marks each phase?
Latent phase: up to 3 to 5 cm dilation; active phase: 4 to 6 cm; transition phase: 7 or 8 to 10 cm

[346] How do the average durations of labor vary between nulliparas and multiparas for the first and
second stages of labor?
First stage: nullipara: 8 to 10 hours (range, 6 to 18 hours); parous woman: 6 to 7 hours (range, 2 to 10
hours). Second stage: nullipara: 50 minutes; parous: 20 minutes.
[347] List four signs that suggest that the placenta has separated.
Uterus has spherical shape; the uterus rises upward in the abdomen; cord descends farther from the
vagina; gush of blood.
[348] Why is it important that the uterus remain firmly contracted after birth?

Firm uterine contraction compresses the bleeding vessels at the placental site to prevent hemorrhage

[349] TABLE: Complete the following chart regarding the characteristics of normal labor
Refer to Table 16-1 in your textbook to complete this exercise.

First Stage Second Stage Third Stage Fourth Stage

Duration Effacement and Expulsion of fetus Separation of Physical recovery
Nullipara: dilation of placenta and bonding with
cervix. Uterine newborn
contractions and Uterine
Uterine voluntary bearing- contractions Uterine
contractions down efforts contraction to
control bleeding
from placental site

Average, 50 min
Latent phase: (range, 30 min–3 5–10 min; up to 1–4 h after birth
approximately h) 30 min is normal
7.5–8.5 h for unassisted
placental
Active phase: separation
8–10 h (range,
6–18 h);
dilation
averages 1.2
cm/h
 Transition
phase:
approximately
3.5 h
Multipara: Latent phase: Average, 20 min Same as for Same as for
approximately (range, 0–30 min) nullipara nullipara
4–5.5 h

Active phase:
6–7 h (range, 2–
10 h); dilation
averages 1.5
cm/h

Transition
phase: 0–30
min
Cervical Dilation Latent phase: 0– 10 cm (complete Not applicable Not applicable
Latent phase: 3 cm dilation)
Active phase: Active phase: no info given no info given no info given
4–10 cm
Transition phase: Transition no info given no info given no info given
phase (if used):
final 8–10 cm
Uterine Contractions Latent phase: Strong, every 2–3 Firmly contracted Firmly contracted
Latent phase: Initially mild min, lasting 40–60
and infrequent; s; may be slightly
progress to less intense than
moderate during transition
strength, every phase of first
5 min with a stage; may pause
regular pattern; briefly as second
duration stage begins
increases to 30–
40 s by end of
latent phase
Active phase: Increase in no info given no info given no info given
frequency,
duration, and
intensity until
every 2–3 min,
40–60 s, and
moderate to
strong intensity
Transition phase: Transition no info given no info given no info given
phase (if used):
Strong, every
1.5–2 min, 60–
90 s
 Discomfort Often begins Urge to push or Little discomfort; Discomfort varies;
with a low bear down with sometimes slight some women have
backache and contractions, cramp is felt as afterpains, more
sensations which becomes placenta is passed common in
similar to those stronger as fetus multigravidas or
of menstrual descends; those who have
cramps; back distention of had a large baby;
discomfort vagina and vulva as anesthesia
gradually may cause a wears off, perineal
sweeps to lower stretching or discomfort may
abdomen in a splitting sensation become noticeable
girdle like
fashion;
discomfort
intensifies as
labor progresses
Maternal Behaviors Sociable, Intense Excited and Tired but may
excited, and concentration on relieved after find it difficult to
somewhat pushing with baby’s birth; rest because of
anxious during contractions; often usually very tired; excitement; eager
early labor; oblivious to often cries to become
becomes more surroundings and acquainted with
inwardly appears to doze her newborn.
focused as labor between
intensifies; may contractions
lose control
during
transition

[350] The two nursing priorities when a woman enters a birth center are to determine Condition of the
mother and fetus and to establish a therapeutic relationship.

[351] When should the nurse not perform a vaginal examination? Why?
Vaginal examination should not be performed if the woman is actively bleeding (not bloody show)
because the examination may increase bleeding.
[352] List important nursing assessments after the membranes rupture. Describe normal and abnormal
assessments, as appropriate.
Time of rupture; whether rupture was spontaneous or artificial; quantity; fetal heart rate (FHR)
for at least 1 minute; color (clear, possibly with bits of vernix, is normal; green indicates fetal
meconium passage; yellow suggests
infection); other characteristics
(cloudy appearance suggests infection); odor (foul or strong odor suggests infection).

[353] Why is it important to place a small pillow under one hip if the mother must lie on her back?
- It is important to place a small pillow under one hip if the mother must lie on her
back to help prevent compression of the inferior vena cava that would reduce blood
flow to the fetus.

[354] What maternal vital signs may indicate problems?

a) Blood pressure: A blood pressure higher than 140/90 could be indicative of preeclampsia.
 b) Temperature: An increased temperature could be indicative of infection commonly known as
chorioamnionitis.

[355] Describe some basic comfort measures the nurse can provide during labor.
- Some basic comfort measures that can be done are providing soft lighting, making
sure the room is a comfortable temperature, position changes, and ensuring that her
bladder is empty.

[356] Immediate nursing care of the newborn includes supporting cardiopulmonary and
thermoregulatory functions and placing identifying bands on infant and mother.

[357] Nursing care of the mother during the fourth stage of labor focuses on observing for hemorrhage
and relieving discomfort.

[358] Discuss the relationship between a full bladder and postpartum hemorrhage.
- When the bladder is full it can displace the uterus and prevent it from contracting
the way that it needs to to stop the bleeding.

CLINICAL JUDGMENT -
[359] A nurse is admitting an 18-year-old primigravida who is in labor. The nurse determines that
Erin's contractions are every 5 minutes of moderate intensity and last 40 seconds. The fetal heart rate
is 135 to 140 beats per minute (bpm), and it accelerates when the fetus moves. Amniotic fluid is light
green with small white flecks in it. The vaginal examination reveals that the cervix is dilated 5 cm
and is completely effaced. The fetal presenting part is hard and round, and a small triangular
depression on the head can be felt in Erin's right posterior pelvis.
Using the table below, use an "X" to indicate whether the assessment findings are Expected
(finding w1thin_ usual limits or parameters), a Common Variation (finding that may or may not
indicate abnormality, usually transitory), or Unexpected (finding that is abnormal and could be
harmful) for the client at this time.
Assessment Findings Expected Common Variation Unexpected
Frequency of contractions Q 5 X
minutes
Intensity of contractions moderate X
Duration of contractions 40 X
seconds
Fetal heartrate baseline of 135- X
145
Fetal accelerations with X
movement
Light green amniotic fluid X
Vaginal exam 5 cm and l00% X
effaced
Presenting part is hard and round X
with triangular depression
palpable

Choose the correct answer.

[360] When assessing a laboring woman's blood pressure, the nurse should:
a) inflate the cuff at the beginning of a contraction.
b) check the blood pressure between two contractions.
 c) expect a slight elevation in blood pressure.
d) position the woman on her back with her knees bent.

[361] A woman is admitted in active labor. Her leukocyte count is 14,500. Based on this information,
the nurse should:
a) assess the woman for other evidence of an infection.
b) promptly inform the nurse-mid if of the results.
c) use isolation techniques to limit the spread of infection.
d) record the expected results in the woman's chart.

[362] The most appropriate time for the nurse to encourage a laboring woman to push is during:
a) the interval between contractions
b) first-stage labor.
c) second-stage labor.
d) whenever she feels the need.

[363] The abbreviation LOA means that the fetal occiput is:
a) on the examiner's left and in the front of the pelvis.
b) in the left front part of the mother's pelvis.
c) anterior to the fetal breech.
d) lower than the fetal breech.

[364] Choose the most reliable evidence that true labor has begun.
a) Regular contractions that occur every 15 minutes.
b) Change in the amount of cervical thinning.
c) Increased ease of breathing with frequent urination.
d) A sudden urge to do household tasks.

[365] The nurse should note how long the interval between contractions lasts because:
a) maternal cells restore their glucose levels during the interval.
b) a very short interval requires earlier administration of analgesia.
c) most exchange of fetal oxygen and waste products occurs.
d) the interval becomes longer as cervical dilation increases.

[366] What is the primary benefit of the stress of labor to the newborn?
a) It stimulates breathing and eliminates lung fluid.
b) It increases alertness and enhances parent-infant bonding.
c) It speeds peristalsis to quickly eliminate meconium
d) It enhances the tolerance of microorganisms from others.

[367] A station of +1 means that the:

a) maternal cervix is open by 1 cm.
b) mother's ischial spines project into her pelvis by 1 cm.
c) fetus is unlikely to be born vaginally because the pelvis is small.
 d) fetal presenting part is 1 cm below the mother's ischial spine.

[368] Bloody show differs from active vaginal bleeding in that bloody show:
a) quickly clots on the perinea! pad.
b) is dark red and mixed with mucus.
c) freely flows from the vagina during vaginal examination.
d) decreases in quantity as labor progresses.

[369] A laboring woman abruptly stops her previous breathing techniques during a contraction and
makes lowpitched grunting sounds. The priority nursing action is to:
a) ask her if she needs pain medication.
b) turn her to her left side.
c) assess contraction duration.
d) look at her perineum.

[370] A woman's membranes rupture during a contraction. The priority nursing action is to:
a) assess the fetal heart rate.
b) note the color of the discharge.
c) check the woman's vital signs.
d) determine whether the fluid has a foul odor.

[371] When palpating labor contractions, the nurse should:

a) use the palm of one hand while palpating the lower uterus.
b) avoid palpating during the period of maximum intensity.
c) place the fingertips over the fundus of the uterus.
d) limit palpations to three consecutive contractions. ·

[372] When performing Leopold's maneuvers, the nurse palpates a hard round object in the uterine
fundus. A smooth rounded surface is on the mother's right side, and irregular, movable parts are felt
on her left side. An irregularly shaped fetal part 1s felt in the suprapubic area and is easily moved
upward. How should these findings be interpreted?
a) The fetal presentation is cephalic, the position is ROA, and the presenting part is engaged.
b) The fetal presentation is cephalic, the pos1t1on 1s LOP, and the presenting part is not engaged.
c) The fetal presentation is breech, the position is RST, and the presenting part is engaged.
d) The fetal presentation is breech, the position is RSA, and the presenting part is not
engaged.

[373] When performing the fourth Leopold's maneuvers, the nurse determines that the cephalic
prominence is on the same side as the fetal back. How should this assessment be interpreted?
a) The fetus is in a breech position with the head extended.
b) The fetus is in a face presentation with the head extended.
c) The fetus is in a transverse lie presentation with the face toward the mother's back.
d) The fetus is in a cephalic presentation with the head well flexed.

[374] The nurse notes the following contraction pattern:

Beginning of Contractions 11:20:00
11:15:00 11:24:00
 11:28:30 11:20:45
11:33:00 11:24:50
End of Contractions 11:29:10
11:15:40 11:33:35
Choose the correct documentation for the pattern.
a) Contractions every 4 to 5 minutes; duration 35 to 50 seconds
b) Contractions every 5 minutes; duration 35 to 40 seconds
c) Contractions every 3 to 5 minutes; duration 30 to 50 seconds
d) Contractions every 3 to 4 minutes; duration 30 to 40 seconds

[375] A woman who is having her third baby planned epidural analgesia for labor and birth. However,
her labor was so rapid that she did not have the epidural. What is the best nursing approach in this
case?
a) Congratulate her on having a labor that was quicker than expected.
b) Use open-ended questions to clarify her true feelings about the experience.
c) Tactfully explain why a non-epidural labor and birth are actually better.
d) Explain that it is often difficult to time epidural analgesia for labor.

[376] A woman having her first baby has been observed for 2 hours for labor but is having false labor
contractions. Choose the most appropriate teaching before she returns home.
a) "It is unlikely that your labor will be fast, so you can stay home until your water breaks."
b) "If your water breaks, you can wait until contractions are 5 minutes apart or closer."
c) "As long as the baby is active, there is no hurry to return to the birth center."
d) "Your contractions will usually be 5 minutes apart or closer for 1 hour if labor is real."