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Prescriptive Authority and Role Implementation in Primary Care Education, Lecture notes of Nursing

The influence of changes in Medicare reimbursement methods and competition from nonphysicians on primary care education in medical schools. It also covers prescribing practices of physicians and the role of nurse practitioners in prescriptive authority. General pharmacokinetic and pharmacodynamic principles are explained, including factors that affect drug excretion and the importance of using generic drug names. The document also covers different drug administration routes and their effects on drug absorption and distribution.

Typology: Lecture notes

2023/2024

Available from 10/09/2023

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Chapter 01: Prescriptive Authority and Role Implementation: Tradition vs.
Change
Test Bank
MULTIPLE CHOICE
1. Which of the following has influenced an emphasis on primary care education in medical
schools?
a. Changes in Medicare reimbursement
methods recommended in 1992
b. Competition from nonphysicians desiring
to meet primary care shortages
c. The need for monopolistic control in the
marketplace of primary outpatient care
d. The recognition that nonphysicians have
variable success providing primary care
ANS: A
The Physician Payment Review Commission in 1992 directly increased financial
reimbursement to clinicians who provide primary care. Coupled with a shortage of
primary care providers, this incentive led medical schools to place greater emphasis on
preparing primary care physicians. Competition from nonphysicians increased
coincidentally as professionals from other disciplines stepped up to meet the needs.
Nonphysicians have had increasing success at providing primary care and have been
shown to be safe and effective.
DIF: Cognitive Level: Remembering (Knowledge) REF: 2
2. Which of the following statements is true about the prescribing practices of physicians?
a. Older physicians tend to prescribe more
appropriate medications than younger
physicians.
b. Antibiotic medications remain in the top
five classifications of medications
prescribed.
c. Most physicians rely on a “therapeutic
armamentarium” that consists of less than
100 drug preparations per physician.
d. The dominant form of drug information
used by primary care physicians continues
to be that provided by pharmaceutical
companies.
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Chapter 01: Prescriptive Authority and Role Implementation: Tradition vs.

Change

Test Bank

MULTIPLE CHOICE

  1. Which of the following has influenced an emphasis on primary care education in medical schools? a. (^) Changes in Medicare reimbursement methods recommended in 1992 b. (^) Competition from nonphysicians desiring to meet primary care shortages c. (^) The need for monopolistic control in the marketplace of primary outpatient care d. (^) The recognition that nonphysicians have variable success providing primary care ANS: A The Physician Payment Review Commission in 1992 directly increased financial reimbursement to clinicians who provide primary care. Coupled with a shortage of primary care providers, this incentive led medical schools to place greater emphasis on preparing primary care physicians. Competition from nonphysicians increased coincidentally as professionals from other disciplines stepped up to meet the needs. Nonphysicians have had increasing success at providing primary care and have been shown to be safe and effective. DIF: Cognitive Level: Remembering (Knowledge) REF: 2
  2. Which of the following statements is true about the prescribing practices of physicians? a. (^) Older physicians tend to prescribe more appropriate medications than younger physicians. b. (^) Antibiotic medications remain in the top five classifications of medications prescribed. c. (^) Most physicians rely on a “therapeutic armamentarium” that consists of less than 100 drug preparations per physician. d. (^) The dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies.

ANS: D Even though most physicians claim to place little weight on drug advertisements, pharmaceutical representatives, and patient preference and state that they rely on academic sources for drug information, a study showed that commercial rather than scientific sources of drug information dominated their drug information materials. Younger physicians tend to prescribe fewer and more appropriate drugs. Antibiotics have dropped out of the top five classifications of drugs prescribed. Most physicians have a therapeutic armamentarium of about 144 drugs. DIF: Cognitive Level: Remembering (Knowledge) REF: 3

  1. As primary care nurse practitioners (NPs) continue to develop their role as prescribers of medications, it will be important to: a. (^) attain the same level of expertise as physicians who currently prescribe medications. b. (^) learn from the experiences of physicians and develop expertise based on evidence- based practice. c. (^) maintain collaborative and supervisorial relationships with physicians who will oversee prescribing practices. d. (^) develop relationships with pharmaceutical representatives to learn about new medications as they are developed. ANS: B As nonphysicians develop the roles associated with prescriptive authority, it will be important to learn from the past experiences of physicians and to develop prescribing practices based on evidence-based medicine. It is hoped that all prescribers, including physicians and nurse practitioners, will strive to do better than in the past. NPs should work toward prescriptive authority and for practice that is not supervised by another professional. Pharmaceutical representatives provide information that carries some bias. Academic sources are better. DIF: Cognitive Level: Applying (Application) REF: 4

Chapter 02: Historical Review of Prescriptive Authority: The Role of Nurses (NPs,

CNMs, CRNAs, and CNSs) and Physician Assistants

Test Bank

MULTIPLE CHOICE

  1. A primary care NP will begin practicing in a state in which the governor has opted out of the federal facility reimbursement requirement. The NP should be aware that this defines

ANS: B CNMs have prescriptive authority in all 50 states. They may treat partners of women for sexually transmitted diseases. They have full prescriptive authority and are not limited to drugs used during childbirth. They practice in many other types of settings. DIF: Cognitive Level: Remembering (Knowledge) REF: 9

  1. In every state, prescriptive authority for NPs includes the ability to write prescriptions: a. (^) for controlled substances. b. (^) for specified classifications of medications. c. (^) without physician-mandated involvement. d. (^) with full, independent prescriptive authority. ANS: B All states now have some degree of prescriptive authority granted to NPs, but not all states allow authority to prescribe controlled substances. Many states still require some degree of physician involvement with certain types of drugs. DIF: Cognitive Level: Understanding (Comprehension) REF: 12
  2. The current trend toward transitioning NP programs to the doctoral level will mean that: a. (^) NPs licensed in one state may practice in other states. b. (^) full prescriptive authority will be granted to all NPs with doctoral degrees. c. (^) NPs will be better prepared to meet emerging health care needs of patients. d. (^) requirements for physician supervision of NPs will be removed in all states. ANS: C The American Association of Colleges of Nursing has recommended transitioning graduate level NP programs to the doctoral level as a response to changes in health care delivery and emerging health care needs. NPs with doctoral degrees will not necessarily have full prescriptive authority or be freed from requirements about physician supervision because those are subject to individual state laws. NPs will still be required to meet licensure requirements of each state. DIF: Cognitive Level: Understanding (Comprehension) REF: 12
  3. An important difference between physician assistants (PAs) and NPs is PAs: a. (^) always work under physician supervision.

b. (^) are not required to follow drug treatment protocols. c. (^) may write for all drug categories with physician co-signatures. d. (^) have both inpatient and outpatient independent prescriptive authority. ANS: A PAs commonly have co-signature requirements and work under physician supervision. DIF: Cognitive Level: Understanding (Comprehension) REF: 17

Chapter 03: General Pharmacokinetic and Pharmacodynamic Principles

Test Bank

MULTIPLE CHOICE

  1. A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African- American woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of: a. (^) bioavailability. b. (^) pharmacokinetics. c. (^) pharmacodynamics. d. (^) anatomy and physiology. ANS: B Pharmacokinetics is the study of the action of drugs in the body and may be thought of as what the body does to the drug. Factors such as age, race, and gender may change the way the body acts to metabolize and excrete a drug. Bioavailability refers to the amount of drug available at the site of action. Pharmacodynamics is the study of the effects of drugs on the body. Anatomy and physiology is a basic understanding of how the body functions. DIF: Cognitive Level: Understanding (Comprehension) REF: 21
  2. A patient asks the primary care NP which medication to use for mild to moderate pain. The NP should recommend: a. (^) APAP. b. (^) Tylenol. c. (^) acetaminophen. d. (^) any over-the-counter pain product. ANS: C

a. (^) is absorbed less quickly. b. (^) has reduced bioavailability. c. (^) has fewer systemic side effects. d. (^) provides dosing that is easier to regulate. ANS: C An inhaled corticosteroid goes directly to the site of action and does not have to pass through gastrointestinal tract absorption or the liver to get to the lungs. It is generally well absorbed at this site, although dosing is not necessarily easier to regulate because it is not always clear how much of an inhaled drug gets into the lungs. DIF: Cognitive Level: Applying (Application) REF: 21

  1. A patient takes an oral medication that causes gastrointestinal upset. The patient asks the primary care NP why the drug information insert cautions against using antacids while taking the drug. The NP should explain that the antacid may: a. (^) alter drug absorption. b. (^) alter drug distribution. c. (^) lead to drug toxicity. d. (^) increase stomach upset. ANS: A Changing the pH of the gastric mucosa can alter the absorption of the drug. Drug distribution is not affected. It may indirectly cause drug toxicity if a significant amount more of the drug is absorbed. It would decrease stomach upset. DIF: Cognitive Level: Applying (Application) REF: 22
  2. A patient will begin taking two drugs that are both protein-bound. The primary care NP should: a. (^) prescribe increased doses of both drugs. b. monitor drug levels, actions, and side effects. c. (^) teach the patient to increase intake of protein. d. (^) stagger the doses of drugs to be given 1 hour apart. ANS: B Protein-bound drugs bind to albumin, and serum albumin levels may affect how drugs are distributed. The provider should monitor drug levels, actions, and side effects and change dosing accordingly. Increasing the dose of both drugs is not recommended unless monitoring indicates. Increasing dietary protein does not affect this. Staggering the drugs

will not affect this. DIF: Cognitive Level: Applying (Application) REF: 25

  1. A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: a. (^) inhibitor. b. (^) substrate. c. (^) inducer. d. (^) metabolizer. ANS: A If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme to metabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. DIF: Cognitive Level: Applying (Application) REF: 26 - 27
  2. The primary care NP should understand that a drug is at a therapeutic level when it is: a. (^) at peak plasma level. b. (^) past 4 or 5 half-lives. c. (^) at its steady plasma state. d. (^) between minimal effective concentration and toxic levels. ANS: D The therapeutic range of a drug is the area between the minimal effective concentration and the toxic concentration. Peak plasma level is the highest level the drug reaches and may be well into the toxic range. Steady state occurs when there is a stable concentration of the drug and generally occurs after 4 or 5 half-lives. DIF: Cognitive Level: Applying (Application) REF: 31
  3. A primary care NP is preparing to prescribe a drug and notes that the drug has nonlinear kinetics. The NP should: a. (^) monitor frequently for desired and adverse effects. b. administer a much higher initial dose as a loading dose. c. (^) monitor creatinine clearance at baseline and periodically.

c. (^) order medications that can be given on an empty stomach. d. (^) instruct the patient to take a lower dose if side effects occur. ANS: A To promote adherence in elderly patients, selecting the smallest number of medications with the simplest dose regimens is recommended, with once-daily dosing preferred. Instructions should be simplified. Drug dosing should be timed with mealtimes to help patients remember to take them. Lower dosing may be necessary with some drugs, but patients should not do this without consulting their provider. DIF: Cognitive Level: Applying (Application) REF: 57 - 58

  1. A 75-year-old patient who lives alone will begin taking a narcotic analgesic for pain. To help ensure patient safety, the NP prescribing this medication should: a. (^) assess this patient’s usual sleeping patterns. b. (^) ask the patient about problems with constipation. c. (^) obtain a baseline creatinine clearance test before the first dose. d. (^) perform a thorough evaluation of cognitive and motor abilities. ANS: D The body system most significantly affected by increased receptor sensitivity in elderly patients is the central nervous system, making this population sensitive to numerous drugs. It is important to evaluate motor and cognitive function before beginning drugs that affect the central nervous system to minimize the risk of falls. Assessment of sleeping patterns is important, but not in relation to patient safety. It is not necessary to evaluate stool patterns or renal function. DIF: Cognitive Level: Applying (Application) REF: 50| 55
  2. A thin 90-year-old patient who will begin taking warfarin has experienced a recent weight loss of 15 pounds. The NP caring for this patient should: a. (^) obtain a baseline liver function test (LFT) before starting the drug. b. (^) write the initial prescription at the lowest possible dose. c. encourage the patient to consume a diet high in fat and protein.

d. (^) counsel the patient to take the drug with food to enhance absorption. ANS: B A common age change that affects the distribution of drugs in older adults is a decrease in serum albumin. Significant changes that may affect drug therapy may be seen in malnourished elderly patients. Warfarin has a high binding affinity with albumin. Significant decreases in albumin may result in a greater free concentration of highly protein-bound drugs. It is important to order the lowest possible dose and titrate upward as needed. A baseline LFT is not indicated. A diet high in fat and protein is not indicated. DIF: Cognitive Level: Applying (Application) REF: 50 - 51

  1. An 86-year-old patient is seen in clinic for a scheduled follow-up after starting a new oral medication 1 month prior. The patient reports no change in symptoms, and a laboratory test reveals a subtherapeutic serum drug level. The NP caring for this patient should: a. (^) consider ordering more frequent dosing of the drug. b. (^) titrate the patient’s dose upward and recheck in 1 month. c. (^) ask the patient about any increased frequency of bowel movements. d. (^) determine the number of pills left in the patient’s prescription bottle. ANS: D Because of cost concerns, poor understanding of a drug’s actions, or confusion about how to take a medication, many elderly patients do not comply with drug regimens and may not take drugs as prescribed. Before increasing the frequency or amount of a drug, it is important to assess first whether or not the patient has been taking the drug as ordered. Counting the number of pills in the bottle will help the provider assess whether the patient is taking the drug as ordered. Changes in gastric motility do not generally have major effects on the effectiveness or serum drug levels of medications. DIF: Cognitive Level: Applying (Application) REF: 57 - 58
  2. An NP learns that a 90-year-old patient is chronically constipated and has frequent problems with acid reflux. The NP notes a weight loss of 20 pounds in this patient in the previous 6 months. Which of the following drugs that this patient is taking is cause for concern? a. (^) Quinidine b. Naproxen c. (^) Calcium citrate d. (^) Calcium channel blocker

Test Bank

MULTIPLE CHOICE

  1. A nurse practitioner (NP) is preparing to prescribe a medication for a 5-year-old child. To determine the correct dose for this child, the NP should: a. (^) calculate the dose at one third of the recommended adult dose. b. (^) estimate the child’s body surface area (BSA) to calculate the medication dose. c. (^) divide the recommended adult dose by the child’s weight in kilograms (kg). d. (^) follow the drug manufacturer’s recommendations for medication dosing. ANS: D The package insert provided by the manufacturer is the best source for pediatric dose recommendations. Approximated reduction in the adult dose is not a safe or effective way of calculating pediatric doses of medications, so using a third of the adult dose may not be safe. Errors inherent in determining BSA make this method less reliable than dose based on accurate weights. Dividing the adult dose by the child’s weight is incorrect. DIF: Cognitive Level: Understanding (Comprehension) REF: 64 - 65
  2. An NP is prescribing a drug that is known to be safe in children but is unable to find recommendations about drug dosing. The recommended adult dose is 100 mg per dose. The child weighs 14 kg. Using Clark’s rule, the NP should order _____ mg per dose. a. (^20) b. (^10) c. (^14) d. (^) 9. ANS: A Clark’s rule suggests dividing the weight of the child in kg by the weight of an adult in kg and multiplying the result by the adult dose to get an approximation of the child’s dose. The average adult weighs 150 lb, or 70 kg. The equation is: 14 kg/70 kg = 0.2. 0.2 100 = 20 mg. DIF: Cognitive Level: Understanding (Comprehension) REF: 65
  3. A child who weighs 22 lb, 2 oz needs a medication. The NP learns that the recommended dosing for this drug is 25 to 30 mg per kg per day in three divided doses. The NP should order:

a. (^) 100 mg daily. b. (^) 100 mg tid. c. (^) 300 mg daily. d. (^) 300 mg tid. ANS: B The NP should first convert the child’s weight to kg, which is about 10 kg. The dose is then calculated to be 250 to 300 mg per day in three divided doses, which is 83 to 100 mg per dose given tid. DIF: Cognitive Level: Applying (Application) REF: 65

  1. The mother of a 3-year-old child who weighs 15 kg tells the NP that she has liquid acetaminophen at home but does not know what dose to give her child. The NP should tell the mother: a. (^) to give 1 teaspoon every 4 to 6 hours as needed. b. (^) to throw away the old medication and get a new bottle. c. (^) that she may give 5 to 7.5 mL per dose every 4 to 6 hours. d. (^) to find out whether she has a preparation made for infants or children. ANS: D Acetaminophen drops for infants are three times as concentrated as the oral liquid for children. The drops have been pulled from the market, but many parents may still have old preparations on hand. The NP should first determine which preparation this mother has before giving dosage recommendations. If the mother has the oral liquid for children, answers A and C would both be acceptable because the concentration is 160 mg per 5 mL. The mother should not be counseled to throw away the medication until the NP has more information. DIF: Cognitive Level: Applying (Application) REF: 65
  2. The parent of a toddler asks the NP about using a topical antihistamine to treat the child’s atopic dermatitis symptoms. The NP should tell the parent that: a. (^) topical medications have fewer side effects in children. b. (^) medications given by this route are not absorbed well in young children. c. topical application of an antihistamine may result in drug toxicity in children.

ANS: D Because the measured volume of “teaspoons” ranges from 2.5 to 7.8 mL, parents should obtain a calibrated medicine spoon or syringe from the pharmacy for dosing small children. Elixirs are solutions in which the drug molecules are dissolved and evenly distributed, so there is no need to shake the drug before each dose. Mixing a drug with food can be problematic if the child does not eat all of the food. An elixir does not need to be administered on an empty stomach. DIF: Cognitive Level: Understanding (Comprehension) REF: 66 - 67| 69

  1. A 4-month-old infant has a viral illness with high fever and cough. The infant’s parent asks the NP about what to give the infant to help with symptoms. The NP should prescribe which of the following? a. (^) Aspirin to treat the fever b. (^) Acetaminophen as needed c. (^) Dextromethorphan for coughing d. (^) An antibiotic to prevent increased infection ANS: B Infants should not be given aspirin, which carries a risk of Reye’s syndrome, or dextromethorphan, which has an increased risk of respiratory depression in infants. An antibiotic is not indicated unless there is a known bacterial infection. Acetaminophen is safe for infants. DIF: Cognitive Level: Applying (Application) REF: 64
  2. A parent brings a 5-year-old child to a clinic for a hospital follow-up appointment. The child is taking a medication at a dose equal to an adult dose. The parent reports that the medication is not producing the desired effects. The NP should: a. (^) order renal function tests. b. (^) prescribe another medication to treat this child’s symptoms. c. (^) discontinue the drug and observe the child for toxic side effects. d. (^) obtain a serum drug level and consider increasing the drug dose. ANS: D By a child’s first birthday, the liver’s metabolic capabilities are not only mature but also more vigorous than the adult liver, meaning that certain drugs may need to be given in higher doses or more often. It is prudent to obtain a serum drug level and then consider increasing the dose to achieve the desired effect. Renal function tests are not indicated. Unless the child is experiencing toxic effects, the drug does not need to be discontinued.

DIF: Cognitive Level: Applying (Application) REF: 62| 66 - 67

  1. An NP is prescribing an antibiotic for a child who will need to take a total of 750 mg per day. Which dosing regimen should the NP prescribe to promote compliance? a. (^) 250 mg/5 mL—375 mg PO bid b. (^) 250 mg/5 mL—250 mg PO tid c. (^) 500 mg/5 mL—375 mg PO bid d. (^) 500 mg/5 mL—250 mg PO tid ANS: C To improve compliance with a drug regimen, convenient dosage forms and dosing schedules should be chosen when possible. A 500 mg/5 mL preparation means that a smaller volume can be given to achieve the desired dose. A bid dosing schedule is more likely to be followed than one that is tid. DIF: Cognitive Level: Applying (Application) REF: 69
  2. An NP sees a preschooler in clinic for the first time. When obtaining a medication history, the NP notes that the child is taking a medication for which safety and effectiveness in children has not been established in drug information literature. The NP should: a. (^) discontinue the medication. b. (^) order serum drug levels to evaluate toxicity. c. (^) report the prescribing provider to the Food and Drug Administration (FDA). d. (^) ask the parent about the drug’s use and side effects. ANS: D Many of the drugs and biologic products most widely used in pediatric patients carry disclaimers stating that safety and effectiveness in pediatric patients have not been established. The NP should find out why the drug was prescribed and whether there are any significant side effects. The medication should not be discontinued unless there are known toxic effects. Serum drug levels may be warranted if side effects are reported. The NP would not report the prescribing provider to the FDA unless there are clear, evidence- based contraindications to prescribing a drug to children. DIF: Cognitive Level: Applying (Application) REF: 67 - 69

Chapter 06: Special Populations: Pregnant and Nursing Women

Test Bank

MULTIPLE CHOICE

rhinitis, which can trigger symptoms. Antihistamines are recommended after the first trimester, if possible. Asthma medications should be continued during pregnancy because poorly controlled asthma can be detrimental to the fetus; she should continue using her daily inhaled corticosteroid. Although discontinuing seizure medications is optimal, this must be done in conjunction with this woman’s neurologist because management of epilepsy during pregnancy is beyond the scope of the primary care provider. Oral corticosteroids have greater systemic side effects and greater effects on the fetus and should be used only as necessary. DIF: Cognitive Level: Applying (Application) REF: 78 - 79

  1. A woman has just learned she is pregnant and is in her 10th gestational week. The woman reports that she takes valproic sodium (Depakote) for a seizure disorder and has been seizure-free for several years. The NP should: a. (^) prescribe folic acid supplements. b. (^) change her antiepileptic drug to lamotrigine (Lamictal). c. (^) order prophylactic vitamin K to be given in the second trimester. d. (^) recommend that she discontinue taking the valproic sodium by 12 weeks. ANS: A Maternal folic acid deficiency is induced by anticonvulsants, especially valproic acid, so folic acid supplements must be given. Although antiepileptic drugs can have consequences for the developing fetus, once a woman is pregnant, the benefit-risk ratio favors continued use of the woman’s current antiepileptic medication, so she should not discontinue the medication or change to lamotrigine. Vitamin K is recommended beginning at 36 weeks of gestation and for the newborn at birth to counter the possibility of hemorrhagic disease of the newborn. DIF: Cognitive Level: Applying (Application) REF: 79
  2. A woman who is pregnant develops gestational diabetes. The NP’s initial action is to: a. (^) prescribe an oral antidiabetic agent. b. (^) give her information about diet and exercise. c. (^) begin treating her with daily insulin injections. d. (^) reassure her that her glucose levels will return to normal after pregnancy. ANS: B Patients with gestational diabetes should be treated with diet and exercise, with insulin

added as needed for poor control. There is insufficient evidence to support the use of oral antidiabetic agents during pregnancy, and some of these are pregnancy category D. Insulin injections may be used but are not the initial intervention. Although glucose levels will return to prepregnancy values in the postpartum period, the NP must initiate therapy. DIF: Cognitive Level: Applying (Application) REF: 79 - 80

  1. A woman who takes an angiotensin converting enzyme inhibitor for hypertension tells her primary care NP that she is trying to get pregnant. The NP should: a. (^) consider replacing her angiotensin converting enzyme inhibitor with methyldopa. b. (^) lower her angiotensin converting enzyme inhibitor dose during the first trimester. c. (^) counsel her to increase her antihypertensive medications during pregnancy. d. (^) add an angiotensin receptor blocker (ARB) during the first trimester of her pregnancy. ANS: A Angiotensin converting enzyme inhibitors, ARBs, and statins are contraindicated during the first trimester of pregnancy and should be discontinued before conception and replaced by safer alternatives, such as methyldopa. The use of antihypertensives during pregnancy remains controversial; increasing the dose is not indicated. DIF: Cognitive Level: Applying (Application) REF: 80
  2. A woman who is pregnant tells an NP that she has been taking sertraline for depression for several years but is worried about the effects of this drug on her fetus. The NP will consult with this patient’s psychiatrist and will recommend that she: a. (^) stop taking the sertraline now. b. (^) continue taking the antidepressant. c. (^) change to a monoamine oxidase inhibitor (MAOI). d. (^) discontinue the sertraline a week before delivery. ANS: B Many women are taking medication for depression before becoming pregnant. Abrupt discontinuation is not recommended, and many clinicians suggest that women at high risk for serious depression during pregnancy might best be served by continuing medication throughout pregnancy. MAOIs may limit fetal growth and are generally discouraged