C HAPTER 19: T HE P REGNANT W OMAN
MULTIPLE CHOICE
1. Which finding is considered normal and expected when the nurse is
performing a physical examination on a pregnant woman?
a. Palpable, full thyroid
b. Edema in one lower leg
c. Significant diffuse enlargement of the thyroid
d. Pale mucous membranes of the mouth
ANS: A
The thyroid may be palpable during pregnancy. It should feel full, but
smooth. Significant diffuse enlargement occurs with hyperthyroidism,
thyroiditis, and hypothyro idism. Pale mucous membranes may indicate
anemia. Bilateral lower extremit y edema is common in pregnancy, but
edema with pain in onl y one leg occurs with deep vein thrombosis.
DIF: Cognitive Level: Appl ying (Application) REF: p. 816 MSC:
Client Needs: Heal th Promotion and Maintenance
2. When auscultating the anterior thorax of a pregnant woman, the nurse
notices the presence of a murmur over the second, third, and fourth
intercostal spaces. The murmur is continuous but can be obliterated by
pressure with the st ethoscope or finger on the thorax just lateral to the
murmur. The nurse interprets this finding to be:
a. Murmur of aortic stenosis.
, b. Most likel y a mammary souffle.
c. Associated with aortic insufficiency.
d. Indication of a patent ductus arteriosus.
ANS: B
Blood flow through the blood vessels, specificall y the internal
mammary artery, can often be heard over the second, third, and fourth
intercostal spaces. This finding is called a mammary souffle , but it may
be mistaken for a cardiac murmur. Th e other options are incorrect.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 816
MSC: Client Needs: Health Promotion and Maintenance
3. When the nurse is assessing the deep tendon reflexes (DTRs) on a woman
who is 32 weeks pregnant, which of these would b e considered a normal
finding on a 0 to 4+ scale?
a. Absent DTRs
b. 2+
c. 4+
d. Brisk reflexes and the presence of clonus
ANS: B
Normall y during pregnancy, the DTRs are 1+ to 2+ and bilaterall y
equal. Brisk or greater than 2+ DTRs and the presence of clonus are
abnormal and may be associated with an elevated blood pressure and
cerebral edema in the preeclamptic woman.
, DIF: Cognitive Level: Appl ying (Application) REF: p. 817 MSC:
Client Needs: Health Promotion and Maintenance
4. When performing an examination of a woman who is 34 weeks pregnant,
the nurse notices amid line linear protrus ion in the abdomen over the area
of the rectus abdominis muscles as the woman raises her head and
shoulders off of the bed. Which response by the nurse is correct?
a. The presence of diastasis recti should be documented.
b. This condition should be discussed w ith the physician because it
will most likel y need to be surgicall y repaired.
c. The possibilit y that the woman has a hernia attributable to the
increased pressure within the abdomen from the pregnancy should
be suspected.
d. The woman should be told that s he may have a difficult time with
delivery because of the weakness in her abdominal muscles.
ANS: A
The separation of the abdominal muscles is called diastasis recti and
frequentl y occurs during pregnancy. The rectus abdominis muscles will
return together after pregnancy with abdominal exercise. This
condition is not a true hernia.
DIF: Cognitive Level: Appl ying (Application) REF: p. 817 MSC:
Client Needs: Health Promotion and Maintenance
5. The nurse is palpating the fundus of a pregnant woman. Which statem ent
about palpation of the fundus is true?
a. The fundus should be hard and slightl y tender to palpation during
the first trimester.
MULTIPLE CHOICE
1. Which finding is considered normal and expected when the nurse is
performing a physical examination on a pregnant woman?
a. Palpable, full thyroid
b. Edema in one lower leg
c. Significant diffuse enlargement of the thyroid
d. Pale mucous membranes of the mouth
ANS: A
The thyroid may be palpable during pregnancy. It should feel full, but
smooth. Significant diffuse enlargement occurs with hyperthyroidism,
thyroiditis, and hypothyro idism. Pale mucous membranes may indicate
anemia. Bilateral lower extremit y edema is common in pregnancy, but
edema with pain in onl y one leg occurs with deep vein thrombosis.
DIF: Cognitive Level: Appl ying (Application) REF: p. 816 MSC:
Client Needs: Heal th Promotion and Maintenance
2. When auscultating the anterior thorax of a pregnant woman, the nurse
notices the presence of a murmur over the second, third, and fourth
intercostal spaces. The murmur is continuous but can be obliterated by
pressure with the st ethoscope or finger on the thorax just lateral to the
murmur. The nurse interprets this finding to be:
a. Murmur of aortic stenosis.
, b. Most likel y a mammary souffle.
c. Associated with aortic insufficiency.
d. Indication of a patent ductus arteriosus.
ANS: B
Blood flow through the blood vessels, specificall y the internal
mammary artery, can often be heard over the second, third, and fourth
intercostal spaces. This finding is called a mammary souffle , but it may
be mistaken for a cardiac murmur. Th e other options are incorrect.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 816
MSC: Client Needs: Health Promotion and Maintenance
3. When the nurse is assessing the deep tendon reflexes (DTRs) on a woman
who is 32 weeks pregnant, which of these would b e considered a normal
finding on a 0 to 4+ scale?
a. Absent DTRs
b. 2+
c. 4+
d. Brisk reflexes and the presence of clonus
ANS: B
Normall y during pregnancy, the DTRs are 1+ to 2+ and bilaterall y
equal. Brisk or greater than 2+ DTRs and the presence of clonus are
abnormal and may be associated with an elevated blood pressure and
cerebral edema in the preeclamptic woman.
, DIF: Cognitive Level: Appl ying (Application) REF: p. 817 MSC:
Client Needs: Health Promotion and Maintenance
4. When performing an examination of a woman who is 34 weeks pregnant,
the nurse notices amid line linear protrus ion in the abdomen over the area
of the rectus abdominis muscles as the woman raises her head and
shoulders off of the bed. Which response by the nurse is correct?
a. The presence of diastasis recti should be documented.
b. This condition should be discussed w ith the physician because it
will most likel y need to be surgicall y repaired.
c. The possibilit y that the woman has a hernia attributable to the
increased pressure within the abdomen from the pregnancy should
be suspected.
d. The woman should be told that s he may have a difficult time with
delivery because of the weakness in her abdominal muscles.
ANS: A
The separation of the abdominal muscles is called diastasis recti and
frequentl y occurs during pregnancy. The rectus abdominis muscles will
return together after pregnancy with abdominal exercise. This
condition is not a true hernia.
DIF: Cognitive Level: Appl ying (Application) REF: p. 817 MSC:
Client Needs: Health Promotion and Maintenance
5. The nurse is palpating the fundus of a pregnant woman. Which statem ent
about palpation of the fundus is true?
a. The fundus should be hard and slightl y tender to palpation during
the first trimester.
