ADVENTIST MEDICAL CENTER COLLEGE

BRGY. SAN MIGUEL, ILIGAN CITY

SCHOOL OF NURSING

CARE OF MOTHER, CHILD, AND ADOLSECENT

First Semester, AY 2023 – 2024

Case Scenario #2 Nursing Care during Normal Pregnancy and Care of the
Developing Fetus

Name of Students: ________________

Date: _______
Score: ____ /40 pts

A PREGNANT WOMAN WITH CONCERNS FOR HER FETUS

Jessica Menendez is a 20-year-old woman who is 20 weeks pregnant. You care for her in an
emergency room after she was stabbed in her upper abdomen from an argument with her
boyfriend.

CHIEF CONCERN:
“Is my baby all right? Do you think the knife hit it?”

HISTORY OF CHIEF CONCERN:

The client and her boyfriend were arguing over who should have the last piece of popcorn in a
bowl when he stabbed her with a kitchen paring knife. The client has felt the fetus move since
the incident; she states movement feels “same as always.” She states, “I know her body parts are
still forming so if a body part is hurt, will a new body part form? What if I start labor and she has
to be born?”

PERSONAL/SOCIAL:
The client lives in one-bedroom apartment. She has a high school education but is unable to find
employment, especially since she’s been pregnant. Finances are provided by government

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assistance. She names her landlord (Mrs. Perez) as her most accessible support person. When
asked if she intended to continue relationship with boyfriend, she answered, “He ain’t all bad.
Just has a bad temper.” She does not intend to press charges against him for the stabbing.

PAST MEDICAL HISTORY:

The client had nephrosis as a preschooler; no apparent sequelae. One previous incident of
intimate partner violence is when a previous boyfriend beat her and broke her wrist. She had no
childhood diseases such as mumps or chickenpox. She had MSAFP test in early pregnancy:
negative result.

FAMILY MEDICAL HISTORY:

Her mother died at age 36 years of uterine cancer. Her father’s health history is unknown. An
aunt has “some kind of heart condition.”

PREGNANCY HISTORY:
Pregnancy planned “to make boyfriend settle down.” Her last menstrual period was January
27th. She has had no prenatal care and not taking prenatal vitamins. Alcohol consumption is “a
beer to help me sleep at night.” She smokes two packs of cigarettes a day; she states she takes no
recreational or prescription drugs.

GYNECOLOGIC HISTORY:
Menarche was at age 11 years, with mild dysmenorrhea each month. She has been sexually
active since age 13 years. She had gonorrhea at age 14 years and was treated at city health center.
She uses a diaphragm for contraception. Because the client trusts her boyfriend to maintain a
monogamous relationship, she does not ask him to use a condom.

REVIEW OF SYSTEMS:
Essentially negative; she has noticed occasional constipation during pregnancy.

PHYSICAL EXAMINATION:

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General appearance: Pregnant-appearing, young adult woman in obvious emotional distress from
recent accident; clothing is blood-stained over abdomen
HEENT: Normocephalic; eyes: follow to all positions of gaze, red reflex present; mucous
membrane appears pale; ears: no redness; TMs mobile; mouth: midline uvula; two
cavities present in lower teeth; four keloid linear scars, each approximately 2 cm long
present on left cheek
Chest: Respiratory rate: 22 breaths/min; no rales or rhonchi present; good aeration all lobes
Abdomen: One-inch, long linear incision type wound present 2 in. above umbilicus at midline;
wound oozing slight serosanguineous drainage; uterus palpable at umbilicus; fetal
movement felt by examiner; FHR: 155 beats/min by fetal heart rate monitor; mild uterine
contractions present on monitor (15 seconds duration every 5 minutes)
Genitalia: Normal female; no discharge or lesions or redness
Extremities: Ecchymotic marks in the impression of a hand present on both upper arms; well-
demarcated ecchymotic marks approximately 2 cm × 3 cm present over tibia on both legs

STUDY QUESTIONS:
1. Jessica’s last menstrual period was January 27th. Based on Naegele’s rule, you would estimate
her expected date of birth to be:
A. October 20.
B. October 27.
C. November 3.
D. November 10.

2. According to McDonald’s rule, at 20 weeks of pregnancy, the distance from Jessica’s

symphysis pubis to the fundus of her uterus should be:

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A. Under 16 cm.
B. 20 cm.
C. Over 25 cm.
D. 16 cm.

3. Jessica reports she smokes more than five packs of cigarettes per day. What is the effect of
smoking cigarettes on fetal development?
A. Nicotine causes low bone density.
B. Smoking results in decreased fetal growth.
C. Cigarettes cause abdominal bloating and increased amniotic fluid viscosity.
D. Cigarette smoke causes fetal hyperglycemia.

4. In early pregnancy, Jessica has a maternal serum α-fetoprotein (MSAFP) level assessed. How
should this test be described to Jessica by the nurse?
A. “It’s a blood serum test to detect neural tube defects.”
B. “It’s an amniotic fluid test to detect sickle-cell anemia.”
C. “It’s a urine test to detect if Rh disease will occur.”
D. “It’s a blood test to detect hemophilia in the fetus.”

5. Which of the following statements should guide the nurse’s interpretation of Jessica’s α-
fetoprotein level?
A. An increased level suggests the fetus may be cognitively challenged.
B. A decreased level suggests the fetus has a serious respiratory disorder.
C. A decreased level suggests the infant may have a chromosomal disorder.
D. A decreased level implies the fetus may have an orthopedic problem.

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6. Jessica doesn’t take prenatal vitamins. Establishing QSEN guidelines to stress teamwork, you
would want to teach your colleagues that the effect on the fetus of not receiving enough folic
acid because of the lack of prenatal vitamins can be:
A. A neural tube anomaly.
B. Congenital talipes disorders.
C. A blood disorder such as anemia.
D. Decreased blood clotting ability.

8. Jessica has a fetal sonogram scheduled to assess for fetal health. Before this procedure, you
would instruct her to do which of the following?
A. To void just before the procedure
B. To drink nothing for 2 hours beforehand
C. To lie on her stomach for the procedure
D. To drink 3 or 4 glasses of liquid beforehand

9. Jessica says she knows her baby’s body parts are still forming. In fact, basic organogenesis is
generally complete by what time during pregnancy?
A. 4 weeks
B. 8 weeks
C. 12 weeks
D. 16 weeks

10. Jessica is concerned her baby will be born early. If a baby is born before surfactant formation
is complete, this can result in what health problem?
A. Valvular disorders
B. Polycythemia or hypocythemia
C. Respiratory distress syndrome
D. Hypoglycemia or polyglycemia

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11. Which would be the most appropriate nursing diagnosis for Jessica?
A. Readiness for enhanced knowledge related to how a fetus develops in utero
B. Risk for injury related to intimate partner violence
C. Confusion related to possible fetal harm as evidenced by smoking during pregnancy
D. Situational low self-esteem related to unstable living situation
(just give rationalization; this is equivalent to 2 points even if there’s no page no.)

12. There is a possibility that Jessica’s trauma could have affected placental hormone production.
A chief hormone secreted by the placenta is:
A. Progesterone.
B. Androgen.
C. Calcium.
D. Insulin.

13. During a nonstress test after her immediate recovery, Jessica showed an acceleration of fetal
heart rate over 15 beats/min from fetal movement 2 times in a 20-minute time period. How
would you interpret her test?
A. Reactive
B. Inconclusive
C. Positive
D. Nonreactive

14. Vibroacoustic stimulation is used during Jessica’s nonstress test. You explain to Jessica that
the purpose of this is to:
A. Wake the fetus by stimulating it with a loud sound.
B. Test the ability of the fetus to hear sound.
C. Stimulate the fetus through electrical activity.
D. Temporarily stimulate Jessica’s autonomic nervous system.

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15. Jessica reports she has felt her fetus move since her accident. A typical fetus moves how
often?
A. One time per each hour
B. Ten times in 60 minutes
C. About 10 times a day
D. Constantly after 16 weeks

16. To determine if there is blood in the amniotic fluid from her accident, Jessica has an
amniocentesis performed. A pocket of amniotic fluid is located by means of:
A. An x-ray.
B. An aspirating needle.
C. A sonogram.
D. Fetoscope.

17. Jessica’s amniotic fluid is inspected for its volume. The most important function of the
amniotic fluid is:
A. To act as a shock absorber.
B. To regulate temperature.
C. To aid in muscular development.
D. To protect the umbilical cord from pressure.

18. Jessica has a biophysical profile done for a baseline measurement. What does this profile
consist of?
A. An estimate of the date Jessica’s labor is most likely to begin
B. An estimate of fetal health based on five different assessments
C. Documentation of the fetal heart rate by electrocardiogram
D. Determination of the fetal gender as well as likely health status

19. When you record Jessica’s fetal heart rate, she states, “That seems awfully fast.” What is a
typical fetal heart rate?

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A. 80 to 120 beats/min
B. 110 to 160 beats/min
C. 160 to 180 beats/min
D. 180 to 200 beats/min

20. Which of the following tests could be used to determine if Jessica’s fetus is mature?
A. A glucose or calcium level below 12 g/ml
B. A neck circumference of over 12 in on X-ray
C. Demonstration of a Moro reflex on sonogram.
D. A lecithin/sphingomyelin ratio of 2:1