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1. A client with a history of bipolar disorder is called by the postpartum support nurse for follow-up. Which symptoms would reassure the nurse that the client is not experiencing a manic episode?
a. Psychomotor agitation and lack of sleep
b. Increased appetite and lack of interest in activities
c. Hyperactivity and distractibility
d. Pressured speech and grandiosity

An increased appetite and a lack of interest would reassure the nurse that the client is not experiencing an episode of mania. Clinical manifestations of a manic episode include at least three of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities. The pregnant woman exhibiting symptoms of a manic episode will likely have a decreased interest in eating and an increased level of interest in pleasurable activities without regard for negative consequences. Psychomotor agitation and a lack of sleep, hyperactivity and distractibility, and pressured speech and grandiosity are all clinical manifestations of a manic episode.


2. When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what is the nurse’s primary concern in planning the client’s care?
a. Displaying outbursts of anger
b. Neglecting her hygiene
c. Harming her infant
d. Losing interest in her husband

Thoughts of harm to herself or to the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger and neglecting personal hygiene are symptoms attributable to PPD, the major concern remains the potential of harm to herself or her infant. Although this client is likely to lose interest in her spouse, it is not the nurse’s primary concern.


3. During an inpatient psychiatric hospitalization, what is the most important nursing intervention?
a. Contacting the client’s significant other
b. Supervising and guiding visits with her infant
c. Allowing no contact with anyone who annoys her
d. Having the infant with the mother at all times

In the hospital setting, the reintroduction of the infant to the mother can and should occur at the mother’s own pace. A schedule is set that increases the number of hours the mother cares for her infant over several days, culminating in the infant staying overnight in the mother’s room. These supervised and guided visits allow the mother to experience meeting the infant’s needs and giving up sleep for the infant. Reintroducing the mother to her infant while in a supervised setting is essential. Another important task for a mother under psychiatric care is to reestablish positive interactions with others.


4. Despite warnings, prenatal exposure to alcohol continues to far exceed exposure to illicit drugs. Which condition is rarely associated with fetal alcohol syndrome (FAS)?
a. Respiratory conditions
b. Intellectual impairment
c. Neural development disorder
d. Alcohol-related birth defects (ARBDs)

Respiratory difficulties are not attributed to exposure to alcohol in utero. Other abnormalities related to FAS include mental retardation, neurodevelopment disorders, and ARBDs.


5. As a powerful central nervous system (CNS) stimulant, which of these substances can lead to miscarriage, preterm labor, placental separation (abruption), and stillbirth?
a. Heroin
b. Alcohol
c. Phencyclidine (1-phenylcyclohexylpiperidine; PCP)
d. Cocaine

Cocaine is a powerful CNS stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth. Heroin is an opiate; its use in pregnancy is associated with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. The most serious effect of alcohol use in pregnancy is FAS. The major concern regarding PCP use in pregnant women is its association with polydrug abuse and its neurobehavioral effects on the neonate.


6. According to research, which risk factor for PPD is likely to have the greatest effect on the client postpartum?
a. Prenatal depression
b. Single-mother status
c. Low socioeconomic status
d. Unplanned or unwanted pregnancy

Prenatal depression has been found to be a major risk factor for PPD. Single-mother status and low socioeconomic status are both small-relationship predictors for PPD. Although an unwanted pregnancy may contribute to the risk for PPD, it does not pose as great an effect as prenatal depression.


7. Which is the most accurate description of PPD without psychotic features?
a. Postpartum baby blues requiring the woman to visit with a counselor or psychologist
b. Condition that is more common among older Caucasian women because they have higher expectations
c. Distinguishable by pervasive sadness along with mood swings
d. Condition that disappears without outside help

PPD is characterized by an intense pervasive sadness along with labile mood swings and is more persistent than postpartum baby blues. PPD, even without psychotic features, is more serious and persistent than postpartum baby blues. PPD is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.


8. While providing care to the maternity client, the nurse should be aware that one of these anxiety disorders is likely to be triggered by the process of labor and birth. Which disorder fits this criterion?
a. Phobias
b. Panic disorder
c. Posttraumatic stress disorder (PTSD)
d. Obsessive-compulsive disorder (OCD)

PTSD can occur as the result of a past trauma such as rape. Symptoms of PTSD include re-experiencing the event, numbing, irritability, angry outbursts, and exaggerated startle reflex. With the increased bodily touch and vaginal examinations that occur during labor, the client may have memories of the original trauma. The process of giving birth may result in her feeling out of control. The nurse should verbalize an understanding and reassure the client as necessary. Phobias are irrational fears that may lead a person to avoid certain events or situations. Panic disorders may occur in as many as 3% to 5% of women in the postpartum period and are described as episodes of intense apprehension, fear, and terror. Symptoms of a panic disorder may include palpitations, chest pain, choking, or smothering. OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck her infant once he or she is born, although she realizes that this behavior is irrational. OCD is optimally treated with medications.


9. Which substance used during pregnancy causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications?
a. Alcohol
b. Caffeine
c. Tobacco
d. Chocolate

Smoking in pregnancy is known to cause a decrease in placental perfusion and is the cause of low-birth-weight infants. Prenatal alcohol exposure is the single greatest preventable cause of mental retardation. Alcohol use during pregnancy can cause high blood pressure, miscarriage, premature birth, stillbirth, and anemia. Caffeine may interfere with certain medications and worsen arrhythmias. Chocolate, particularly dark chocolate, contains caffeine that may interfere with certain medications.


10. As part of the discharge teaching, the nurse can prepare the mother for her upcoming adjustment to her new role by instructing her regarding self-care activities to help prevent PPD. Which statement regarding this condition is most helpful for the client?
a. Stay home, and avoid outside activities to ensure adequate rest.
b. Be certain that you are the only caregiver for your baby to facilitate infant attachment.
c. Keep your feelings of sadness and adjustment to your new role to yourself.
d. Realize that PPD is a common occurrence that affects many women.

Should the new mother experience symptoms of the baby blues, it is important that she be aware that these symptoms are nothing to be ashamed of. As many as 10% to 15% of new mothers experience similar symptoms. Although obtaining enough rest is important for the mother, she should not distance herself from her family and friends. Her spouse or partner can communicate the best visiting times to enable the new mother to obtain adequate rest. It is also important that she not isolate herself at home by herself during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant’s care. If depression occurs, then the symptoms will often interfere with mothering functions; therefore, family support is essential. The new mother should share her feelings with someone else and avoid overcommitting herself or feel as though she has to be superwoman. A telephone call to the hospital “warm line” may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.


11. A woman at 24 weeks of gestation states that she has a glass of wine with dinner every evening. Why would the nurse counsel the client to eliminate all alcohol?
a. Daily consumption of alcohol indicates a risk for alcoholism.
b. She will be at risk for abusing other substances as well.
c. The fetus is placed at risk for altered brain growth.
d. The fetus is at risk for multiple organ anomalies.

No period exists when consuming alcohol during pregnancy is safe. The documented effects of alcohol consumption during pregnancy include mental retardation, learning disabilities, high activity level, and short attention span. The brain grows most rapidly in the third trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has not been linked to alcohol use.


12. A pregnant woman who abuses cocaine admits to exchanging sex to finance her drug habit. This behavior places the client at the greatest risk for what?
a. Depression of the CNS
b. Hypotension and vasodilation
c. Sexually transmitted infections (STIs)
d. Postmature birth

Exchanging sex acts for drugs places the woman at increased risk for STIs because of multiple partners and the lack of protection. Cocaine is a CNS stimulant that causes hypertension and vasoconstriction. Premature delivery of the infant is one of the more common problems associated with cocaine use during pregnancy.


13. What is the most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant?
a. Genetic changes and anomalies
b. Extensive CNS damage
c. Fetal addiction to the substance inhaled
d. Intrauterine growth restriction

The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes will not normally cause genetic changes or extensive CNS damage. Addiction to tobacco is not a usual concern related to the neonate.


14. The use of methamphetamine (meth) has been described as a significant drug problem in the United States. The nurse who provides care to this client population should be cognizant of what regarding methamphetamine use?
a. Methamphetamines are similar to opiates.
b. Methamphetamines are stimulants with vasoconstrictive characteristics.
c. Methamphetamines should not be discontinued during pregnancy.
d. Methamphetamines are associated with a low rate of relapse.

Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are similarly used. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is extremely high.


15. With one exception, the safest pregnancy is one during which the woman is drug and alcohol free. What is the optimal treatment for women addicted to opioids?
a. Methadone maintenance treatment (MMT)
b. Detoxification
c. Smoking cessation
d. 4 Ps Plus

MMT is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for the treatment of opioid addiction that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease the rates of infections such as hepatitis B and C, human immunodeficiency virus (HIV), and other STIs. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool specifically designed to identify pregnant women who need in-depth assessment related to substance abuse.


1. Reports have linked third trimester use of selective serotonin uptake inhibitors (SSRIs) with a constellation of neonatal signs. The nurse is about to perform an assessment on the infant of a mother with a history of a mood disorder. Which signs and symptoms in the neonate may be the result of maternal SSRI use? (Select all that apply.)
a. Hypotonia
b. Hyperglycemia
c. Shivering
d. Fever
e. Irritability

ANS: C, D, E
Neonatal signs of maternal SSRI use include continuous crying, irritability, jitteriness, shivering, fever, hypertonia, respiratory distress, feeding difficulty, hypoglycemia, and seizures. The onset of signs and symptoms ranges from several hours to several days after birth, but the signs generally resolve within 2 weeks.


2. Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps Plus is a screening tool specifically designed to identify the need for a more in-depth assessment. Which are the correct components of the 4 Ps Plus? (Select all that apply.)
a. Parents
b. Partner
c. Present
d. Past
e. Pregnancy

ANS: A, B, D, E
The nurse who is screening the client using the 4 Ps Plus would use the following format: Parents: “Did either of your parents have a problem with alcohol or drugs?” Partner: “Does your partner have a problem with alcohol or drugs?” Past: “Have you ever had any beer, wine, or liquor?” Pregnancy: “In the month before you knew you were pregnant, how many cigarettes did you smoke? How much beer, wine, or liquor did you drink?” Present: Is not a component of the 4 Ps Plus.


Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?
a. Heroin
b. Alcohol
c. Phencyclidine palmitate (PCP)
d. Cocaine

Ans: A
The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. Alcohol, PCP, and cocaine are not opiates.


During pregnancy, alcohol withdrawal may be treated using:
a. Disulfiram (Antabuse).
b. Corticosteroids.
c. Benzodiazepines.
d. Aminophylline.

Ans: C
Symptoms that occur during alcohol withdrawal can be managed with short-acting barbiturates or benzodiazepines. Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids and aminophylline are not used to treat alcohol withdrawal.


To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features:
a. Is more likely to occur in women with more than two children.
b. Is rarely delusional and is usually about someone trying to harm her (the mother).
c. Although serious, is not likely to need psychiatric hospitalization.
d. Is typified by auditory or visual hallucinations.

Ans: D
Hallucinations are present in 25% of women with this disorder; paranoid or grandiose delusions (present in 50%), elements of delirium or disorientation, and extreme deficits in judgment accompanied by high levels of impulsivity may contribute to risks of suicide or infanticide. PPD is more likely to occur in first-time mothers. PPD with psychosis is a psychiatric emergency that requires hospitalization.


Nurses must be cognizant of the growing problem of methamphetamine use during pregnancy. When caring for a woman who uses methamphetamines, it is important for the nurse to be aware of which factor related to the abuse of this substance?
a. Methamphetamine is a depressant.
b. All methamphetamines are vasodilators.
c. Methamphetamine users are extremely psychologically addicted.
d. Rehabilitation is usually successful.

Ans: C
“Meth” users are extremely psychologically addicted. Typically these women display poor control over their behavior and a low threshold for pain. This substance is relatively inexpensive and easy to obtain. Methamphetamine is a stimulant and a vasoconstrictor. The rate of relapse for methamphetamine users is very high.


Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps-Plus is a screening tool designed specifically to identify when there is a need for a more in-depth assessment. Which of the following is not included in the 4 Ps-Plus screening tool?
a. Present
b. Partner
c. Past
d. Pregnancy

Ans: A
The first P is Parents: The woman should be asked, “Did either of your parents have a problem with alcohol or drugs?” The second P is Partner: “Does your partner have a problem with alcohol or drugs?” The third P is Past: “Have you ever had any beer, wine, or liquor?” The fourth P is Pregnancy: “In the month before you knew you were pregnant, how many cigarettes did you smoke? How much beer, wine, or liquor did you drink?”


The 5 As screening intervention tool is used to implement smoking cessation strategies on the basis of patient response. What do the 5 As stand for?
a. Ask, advise, administer, approve, and admit
b. Ask, assess, advise, assist, and arrange follow-up
c. Assess, assist, advise, apply, and arrange
d. Assess, apply, advise, ask, and arrange follow-up

Ans: B
The 5 As stand for ask, assess, advise, assist, and arrange follow-up.


Which of these medications would be classified as a Category X substance that is not to be used during pregnancy?
a. Lorazepam (Ativan)
b. Alprazolam (Xanax)
c. Chlordiazepoxide (Librium)
d. Temazepam (Restoril)

Ans: D
Restoril is classified as a Category X drug and is contraindicated during pregnancy on the basis of clinical studies. Ativan, Xanax, and Librium are classified as Category D drugs and as such would not be given during pregnancy unless a benefits to risks ratio was established.


A nurse is advising a pregnant patient who has a substance abuse problem about a contingency management program. Which statement identifies an aspect of this type of program?
a. Pregnant woman are confined to an inpatient treatment method during their pregnancy.
b. Pregnant woman are given biofeedback modalities as stimulus responses to control their addiction.
c. Pregnant woman are given motivational incentives as a primary approach to stop their drug abuse problem.
d. Pregnant woman must follow a strict medication nutritional program during the course of pregnancy.

Ans: C
A contingency management program utilizes a motivational incentive approach with patients to support their efforts to maintain abstinence. The incentives may include small cash amounts, privileges, or prizes. Contingency management programs are not limited to inpatient settings and do not involve biofeedback modalities or medication nutritional programs.


Where do most deliveries for pregnant women who have mental health issues take place?
a. Mental health hospital setting
b. Midwife assisted births
c. Community hospital settings
d. Psychiatric hospitals on locked units

Ans: C
Unless there is some specific psychiatric mental health issue that requires that a patient remain in a locked unit, most pregnant women who have mental health issues deliver in community settings. Although midwives are trained to provide obstetric care, they typically do not take care of complex patients, and a woman who had a diagnosed mental health issue would be classified as a complex patient.


Which of the following statements about the prevalence of perinatal mental health problems is true? (Select all that apply.)
a. The World Health Organization (WHO) recognizes postpartum depression as the leading cause of disability in women.
b. Up to a ¼ of pregnant women will experience some aspect of depression during their pregnancies.
c. Income status plays a significant role in the presentation of perinatal mental health problems.
d. A higher incidence of postpartum depression (PPD) is found in about 50% of the population.
e. Between 30 and 50 billion dollars accounts for productivity and direct medical costs related to depression in women.

Ans: B, C, E
The WHO recognizes depression as the leading cause of disability in women. Between 14% and 23% of women will experience some aspect of depression during their pregnancies. Low income plays a significant factor in the presentation of perinatal mental health problems. Higher incidence of PPD is found in about 25% of women. The economic costs related to depression treatment in women are extremely high, ranging between 30 and 50 billion dollars.