Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition
MULTIPLE CHOICE
1. A patient with gestational hypertension is exhibiting all of the signs listed. What should
the nurse report immediately?
a. Diarrhea
b. Urticaria
c. Blurred vision
d. Backache
ANS: C
Visual disturbances indicate worsening gestational hypertension and must be reported
promptly for effective intervention to prevent severe pre-eclampsia and convulsion.
DIF: Cognitive Level: Application REF: 105 OBJ: 4
TOP: Gestational Hypertension KEY: Nursing Process Step: Planning
2. A patient who is 28 weeks pregnant presents with gestational hypertension. What need
would the nurse make the first priority?
a. Bed rest
b. Decrease protein intake
c. Limiting fluid intake
d. Instruction about fetal kick counts
ANS: D
Fetal kick counts can be reassuring that the fetus remains healthy in the uterus. Bed
rest is not recommended for women because of the increased risk of complications it
causes. Activity restriction is recommended.
DIF: Cognitive Level: Application REF: 106 OBJ: 4
TOP: Gestational Hypertension KEY: Nursing Process Step:
, Implementation
3. A nurse is caring for a pregnant woman diagnosed with pre-eclampsia. What will the
nurse explain is the objective of magnesium sulphate therapy for this patient?
a. To prevent seizures
b. To promote diaphoresis
c. To increase reflex irritability
d. To act as a diuretic
ANS: A
Magnesium sulphate is a central nervous system depressant given to prevent seizures.
DIF: Cognitive Level: Knowledge REF: 105 OBJ: 4
TOP: Magnesium Sulphate KEY: Nursing Process Step: Implementation
4. A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the
nurse explain that hyperemesis gravidarum is distinguished from morning sickness?
a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
d. The woman with hyperemesis gravidarum will have persistent vomiting without
weight loss.
ANS: B
Dehydration and electrolyte imbalances result from persistent nausea and vomiting
associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the
placenta.
DIF: Cognitive Level: Comprehension REF: 92 OBJ: 3
TOP: Hyperemesis KEY: Nursing Process Step: Implementation
5. A nurse is caring for a pregnant woman receiving an intravenous infusion with
magnesium sulphate. What is the highest priority nursing intervention?
a. Count respirations and report a rate of less than 12 breaths/minute.
b. Count respirations and report a rate of more than 20 breaths/minute.
c. Check blood pressure and report a rate of less than 100/60 mm Hg.
MULTIPLE CHOICE
1. A patient with gestational hypertension is exhibiting all of the signs listed. What should
the nurse report immediately?
a. Diarrhea
b. Urticaria
c. Blurred vision
d. Backache
ANS: C
Visual disturbances indicate worsening gestational hypertension and must be reported
promptly for effective intervention to prevent severe pre-eclampsia and convulsion.
DIF: Cognitive Level: Application REF: 105 OBJ: 4
TOP: Gestational Hypertension KEY: Nursing Process Step: Planning
2. A patient who is 28 weeks pregnant presents with gestational hypertension. What need
would the nurse make the first priority?
a. Bed rest
b. Decrease protein intake
c. Limiting fluid intake
d. Instruction about fetal kick counts
ANS: D
Fetal kick counts can be reassuring that the fetus remains healthy in the uterus. Bed
rest is not recommended for women because of the increased risk of complications it
causes. Activity restriction is recommended.
DIF: Cognitive Level: Application REF: 106 OBJ: 4
TOP: Gestational Hypertension KEY: Nursing Process Step:
, Implementation
3. A nurse is caring for a pregnant woman diagnosed with pre-eclampsia. What will the
nurse explain is the objective of magnesium sulphate therapy for this patient?
a. To prevent seizures
b. To promote diaphoresis
c. To increase reflex irritability
d. To act as a diuretic
ANS: A
Magnesium sulphate is a central nervous system depressant given to prevent seizures.
DIF: Cognitive Level: Knowledge REF: 105 OBJ: 4
TOP: Magnesium Sulphate KEY: Nursing Process Step: Implementation
4. A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the
nurse explain that hyperemesis gravidarum is distinguished from morning sickness?
a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
d. The woman with hyperemesis gravidarum will have persistent vomiting without
weight loss.
ANS: B
Dehydration and electrolyte imbalances result from persistent nausea and vomiting
associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the
placenta.
DIF: Cognitive Level: Comprehension REF: 92 OBJ: 3
TOP: Hyperemesis KEY: Nursing Process Step: Implementation
5. A nurse is caring for a pregnant woman receiving an intravenous infusion with
magnesium sulphate. What is the highest priority nursing intervention?
a. Count respirations and report a rate of less than 12 breaths/minute.
b. Count respirations and report a rate of more than 20 breaths/minute.
c. Check blood pressure and report a rate of less than 100/60 mm Hg.
