ATI RN
Common Complications in Early Pregnancy Questions
Question 1 of 5
The nurse auscultates a functional systolic murmur, grade II/IV, on a woman in week 30 of her pregnancy. The remainder of her physical assessment is within normal limits. The nurse would:
Correct Answer: C
Rationale: Rationale: The correct answer is C. During pregnancy, there is a physiological increase in blood volume to support the growing fetus and maternal needs. This increased volume can lead to the development of functional systolic murmurs, which are typically benign and do not indicate underlying heart abnormalities. Therefore, it is crucial for the nurse to recognize that this finding is a normal adaptation to pregnancy and does not require further investigation or intervention. Option A is incorrect because referring the woman for additional consultation based solely on the presence of a functional systolic murmur in pregnancy would be unnecessary and could cause undue anxiety for the patient. Option B is incorrect as asking the woman to run briefly in place to assess for an increase in murmur intensity is not necessary. Functional systolic murmurs in pregnancy are typically consistent in intensity and do not change significantly with activity. Option D is incorrect as there is no indication to restrict the woman's activities or schedule a re-evaluation in 1 week based on the presence of a functional systolic murmur in isolation. Educationally, understanding the normal physiological changes that occur during pregnancy is essential for healthcare providers to differentiate between benign adaptations and potential complications. This knowledge helps prevent unnecessary interventions and ensures appropriate care for pregnant women.
Question 2 of 5
When the nurse is assessing the deep tendon reflexes (DTRs) on a woman who is 32 weeks pregnant, which of these would be considered a normal finding on a 0 to 4+ scale?
Correct Answer: B
Rationale: In early pregnancy, changes in the body can affect deep tendon reflexes (DTRs). The correct answer is B) 2+. A normal DTR response in pregnancy is typically 2+ on a 0 to 4+ scale. This indicates a normal response without hyperactivity or diminished reflexes. Option A) Absent DTRs would be considered abnormal and could indicate issues such as nerve damage or disease. Option C) 4+ indicates hyperactive reflexes, which are not normal and could be a sign of certain neurological conditions. Option D) brisk reflexes and the presence of clonus suggest hyperreflexia, which is also abnormal in pregnancy. Educationally, understanding the normal changes in pregnancy, including DTR assessments, is crucial for nurses caring for pregnant women. Knowing what is normal helps in identifying potential complications early and providing appropriate care. Regular monitoring and assessment of DTRs can aid in detecting any abnormalities promptly, ensuring the well-being of both the mother and the developing fetus.
Question 3 of 5
The nurse is palpating the fundus of a pregnant woman. Which statement about palpation of the fundus is true?
Correct Answer: C
Rationale: The correct answer is C because after 20 weeks gestation, the number of centimeters should approximate the number of weeks gestation. This helps in assessing the growth and development of the fetus within the uterus. The other choices do not accurately reflect the true nature of fundal palpation during pregnancy.
Question 4 of 5
A woman at 25 weeks gestation comes to the clinic for her prenatal visit. The nurse notices that her face and lower extremities are swollen, and her blood pressure is 154/94 mm Hg. The woman states that she has had headaches and blurry vision but thought she was just tired. What should the nurse suspect?
Correct Answer: B
Rationale: The symptoms described by the woman, including elevated blood pressure, proteinuria, headaches, and visual changes are classic signs of preeclampsia. Eclampsia is characterized by seizures, which are not mentioned in the scenario. Diabetes type 1 and preterm labor do not present with the same symptoms as described.
Question 5 of 5
During a woman's 34th week of pregnancy, she is told that she has preeclampsia. The nurse knows which statement concerning preeclampsia is true?
Correct Answer: D
Rationale: Untreated preeclampsia can progress to eclampsia, which can have serious consequences for both the mother and the fetus, including restriction of fetal growth. Edema is common in pregnancy but is not a specific indicator of preeclampsia. Eclampsia can occur before or after delivery, not just before.