Comprehensive Review for the NCLEX-PN EXAM Maternity
A woman who thinks she could be pregnant calls her neighbor, a practical nurse (PN), to ask when she should use a home pregnancy test to diagnose pregnancy. Which response is best? A) "A home pregnancy test can be used right after your first missed period." B) "These tests are most accurate after you have missed your second period." C) "Home pregnancy tests often give false-positives and should not be trusted." D) "The test can provide accurate information when used right after ovulation."
A) "A home pregnancy test can be used right after your first missed period." Rationale: Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception and is best detected at 2 weeks' gestation or immediately after the first missed period.
Which over-the-counter medication should the practical nurse recommend that a breast-feeding mother avoid? A) Famotidine (Pepcid) B) Ibuprofen (Motrin) C) acetylsalicylic acid (Aspirin) D) loratadine (Claritin)
A) acetylsalicylic acid (aspirin) Rationale: breast-feeding mother should avoid any products containing acetylsalicylic acid (aspirin) because of the possible association with reye syndrome and the infant.
Twenty-four hours after a full-term newborn is admitted to the newborn nursery, the practical nurse (PN) observes a localized swelling on the right side of the head of the newborn. What is the most likely cause of this accumulation of blood between the periosteum and skull, which does not cross the suture line in a newborn? A) A cephalhematoma, which is caused by forceps trauma B) A subarachnoid hematoma, which requires immediate drainage C) Molding, which is caused by pressure during labor D) A subdural hematoma, which can result in lifelong damage
A) A cephalhematoma, which is caused by forceps trauma Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. What instruction should the practical nurse (PN) reinforce to this client? A) Breastfeed the infant, ensuring that both breasts are completely emptied. B) Pump the infected breast to avoid pain of the infant latching onto the infected breast. C) Breastfeed on the unaffected breast only until the mastitis subsides. D) Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
A) Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale: Mastitis (caused by plugged milk ducts) is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.
The practical nurse (PN) attempts to help a teenage client with her feelings following a spontaneous abortion at 8 weeks' gestation. What type of emotional response should the PN anticipate? A) Grief related to her perceptions about the loss of this child B) Relief of ambivalent feelings experienced with this pregnancy C) Shock because she may not have realized that she was pregnant D) Guilt because she had not followed her health care provider's instructions
A) Grief related to her perceptions about the loss of this child Rationale: A grief and loss response occurs at all stages of pregnancy loss.
The nurse explains to a new mother why the baby needs a vitamin K injection. Which statement by the mother indicates adequate understanding? A) "Newborn babies need vitamin K to prevent bleeding." B) "Vitamin K is given to newborns to boost their immunity." C) "Vitamin K goes in my baby's eyes to prevent a bacterial infection." D) "My baby needs the vitamin K because she has a low potassium level."
A) Newborn babies need vitamin K to prevent bleeding Rationale: The body requires vitamin K for coagulation. Newborns are born with deficient levels of vitamin K, so the vitamin K injections are given to prevent bleeding disorders
The practical nurse is reinforcing teaching to a new mother about diet and breast-feeding. Which instruction is most important to include? A) avoid alcohol because it is excreted in breastmilk B) eat a high roughage diet to help prevent constipation C) increased caloric intake by approximately 500 cal/day D) increase fluid intake to 3 quarts/day
A) avoid alcohol because it is excreted in breastmilk Rationale: alcohol should be avoided while breast-feeding because when consumed by the mother, it is excreted in the breastmilk and may cause a variety of problems for the infant.
The practical nurse (PN) is teaching a couple about ovulation and conception. Which statement by the PN gives the most likely time for conception to occur? A) Two weeks before menstruation B) Immediately after menstruation C) Immediately before menstruation D) Three weeks before menstruation
A) Two weeks before menstruation Rationale: Ovulation occurs 14 days before the first day of the menstrual period.
Following vaginal delivery in a birthing suite, the practical nurse determines that a newborn has cyanotic hands and feet and has a respiratory rate of 58 breaths/minute. What action should the practical nurse implement? A) continue to observe the infant B) administer oxygen at 5 L/minute C) notify the pediatrician immediately D) transfer the infant to the nursery
A) continue to observe the infant Rationale: The newborn infant respirations should range between 40 and 60 breaths per minute. Acrocyanosis (bluing of the hands and feet) is a normal occurrence at birth and should not be confused with central cyanosis, which reflects impaired gas exchange and is exhibited by the neonate's skin and mucous membranes turning blue.
The practical nurse is caring for a gravida 4, para 3 admitted to the antepartum unit in preterm labor at 32 weeks gestation. The client has previously been diagnosed with rheumatic heart disease. Which assessment findings indicate the onset of cardiac failure requiring immediate intervention? A) edema, basilar rales, and tachycardia B) increased urinary output and irregular heart rate C) shortness of breath, bradycardia, and hypertension D) regular heart rate and hypertension
A) edema, basilar rales, and tachycardia Rationale: edema, basilar rales, and and an irregular pulse indicate cardiac decompensation and require immediate intervention.
The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse notes that the clients temperature is 100.4°F. Which intervention should the nurse implement? A) encourage fluids to increase hydration B) recheck the temperature and 15 minutes C) place an ice pack on the clients forhead D) call the physician for an order for acetaminophen (Tylenol)
A) encourage fluids to increase hydration Rationale: it is normal for the postpartum client to have a temperature up to 100.4°F because of dehydration caused by labor. The most appropriate intervention is to encourage fluids to rehydrate the patient.
The practical nurse is assessing a client at 20 weeks gestation. What measurement should be compared with the clients current weight to obtain the most accurate data about her weight gain during the entire pregnancy? A) usual prepregnancy weight B) Weight at the first prenatal visit C) previous pregnancy weight gain D) daily weight gains or losses
A) usual prepregnancy weight Rationale: comparing the clients current weight with her prepregnancy weight allows for calculation of total weight gain.
A pregnant client is scheduled for an amniocentesis. The client asks the nurse what to expect during the procedure. How should the nurse respond? (Select all that apply.) A) "The nurse will be checking your vital signs every 15 minutes." B) "You should expect to have a low-grade fever after the procedure." C)"Amniocentesis is noninvasive, and it is used to look for fetal anomalies." D) "You will be positioned on your back during the procedure and on your left side following the procedure." E) "Uterine contractions or cramping following the procedure are not normal and should be reported to your health care provider."
A, D, & E) "The nurse will be checking your vital signs every 15 minutes." "You will be positioned on your back during the procedure and on your left side following the procedure." "Uterine contractions or cramping following the procedure are not normal and should be reported to your health care provider." Rationale: During the procedure and recovery, the client's vital signs should be monitored every 15 minutes. The client should expect to be positioned supine during the procedure and on the left side following the procedure. Uterine contractions or cramping may be a sign of premature labor and should be reported to the health care provider immediately.
The nurse is preparing a 3-day-old, full term newborn for discharge home. The baby's mother is HIV-positive. For which procedure should the practical nurse wear gloves? (Select all that apply) A) diaper changes B) obtaining vital signs C) formula feeding D) newborn hearing screening E) heel stick for metabolic screening F) discharge bath
A,E) diaper changes and heel stick for metabolic screening Rationale: after the infant has been given the admission bath, the PN should wear gloves only in those situations in which there is a potential for the presence of HIV positive blood and body fluids.
The nurse educates the pregnant client about a new diagnosis of gestational diabetes. Which statement made by the client indicates the need for further education? A) "I should watch for signs of infection and report them to my doctor." B) "My doctor will prescribe oral medication to help keep my blood sugars normal." C) "I should continue to exercise because it will help keep my blood glucose levels down." D) "If I can't control my blood sugar with diet alone, my provider may prescribe insulin."
B) "My doctor will prescribe oral medication to help keep my blood sugars normal." Rationale: Oral hypoglycemics are not prescribed during pregnancy because teratogenic effects. Most important factor is new diagnosis of diabetes.
A new mother asks the practical nurse (PN), "How do I know that my daughter is getting enough breast milk?" Which explanation best supports that the mother has adequate milk supply? A) "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B) "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C) "Offer the baby extra bottle milk after her feeding, and see if she is still hungry." D) "If you're concerned, you might consider bottle feeding so that you can monitor her intake."
B) "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." Rationale: The urine will be dilute (straw-colored) and frequent (greater than six to ten times/day) if the infant is adequately hydrated.
While reviewing a new postpartum client's plan of care, the practical nurse (PN) notes that the priority nursing diagnosis is "Impaired tissue integrity: fourth-degree laceration." Based on this nursing diagnosis, which intervention should the PN implement? A) Apply ice to the perineum for the next 48 hours. B) Administer prescribed docusate sodium (Colace). C) Demonstrate positions of comfort when sitting. D) Medicate for pain q4 to 6h PRN.
B) Administer prescribed docusate sodium (Colace). Rationale: The PN's first action should be to administer the prescribed stool softener because a fourth-degree laceration extends through the anal sphincter and anterior rectal wall, so constipation or straining with stool can further damage the repaired tissue.
The practical nurse (PN) is caring for a client who had a normal vaginal delivery. During the first 4 hours that the client is on the postpartum unit, the nurse palpates the uterine fundus and bladder qh. What is the primary reason for implementing this nursing intervention? A) A full bladder after delivery is an indicator to ambulate the client in order to prevent phlebothrombosis. B) An overdistended bladder could inhibit uterine contraction and predispose to postpartum bleeding. C) Urine specimens for glucose and protein must be obtained at intervals to monitor for preeclampsia states. D) A firm fundus will promote frequent voiding and minimizes the need for catheterization.
B) An overdistended bladder could inhibit uterine contraction and predispose to postpartum bleeding Rationale: A distended, full bladder can impair the efficiency of uterine contraction, which will allow uterine sinuses to bleed and result in the fundus becoming displaced and boggy in consistency.
A client in active labor begins to experience cramps in her leg. What intervention should the practical nurse (PN) implement? A) Massage the calf and foot B) Extend the leg and dorsiflex the foot C) Lower the leg off the side of the bed D) Elevate the leg above the heart
B) Extend the leg and dorsiflex the foot Rationale: Dorsiflexing the foot by pushing the foot upward or by standing and putting the heel of the foot on the floor is the best means of relieving leg cramps, because it creates an opposing action to relax the gastrocnemius.
During a prenatal visit, the practical nurse (PN) discusses with a client the effects that smoking has on the fetus. Which statement is most characteristic of an infant whose mother smoked during pregnancy as compared with the infant of a nonsmoking mother? A) Lower Apgar score recorded at delivery B) Lower initial weight documented at birth C) Higher oxygen use to stimulate breathing D) Higher prevalence of congenital anomalies
B) Lower initial weight documented at birth Rationale: Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy.
During a routine prenatal visit, a woman at 38 weeks' gestation tells the practical nurse (PN) that both her cousin and her cousin's 1-year-old daughter have phenylketonuria (PKU). The client expresses concern that her unborn child may also have PKU and become mentally retarded. Which information should the PN provide? A) An infant with PKU is given a special formula and diet. B) PKU screening is performed after the newborn ingests milk. C) Genetic testing of the client can identify PKU in the infant. D) The fetus's risk for PKU is only slightly higher than usual.
B) PKU screening is performed after the newborn ingests milk. Rationale: PKU is an inborn error of metabolism resulting in an elevated serum amino acid, phenylalanine, which causes mental retardation. (B) describes the accurate screening for PKU, after the newborn has ingested breast milk or formula milk protein.
A mother who is positive for the HIV virus delivers a 7-pound boy. Which intervention should the practical nurse initiate to prevent transfer of the virus to the infant? A) Provide a particulate filter mask for the mother to wear when interacting with the baby. B) Prevent breastfeeding but encourage rooming-in. C) Clean the skin with alcohol before administering a Vitamin K injection. D) Teach the mother to glove during diaper changes.
B) Prevent breastfeeding but encourage rooming-in. Rationale: Rooming-in should be allowed, but transmission of the mother's body fluids (breast milk) should be prevented. Standard precautions should be instituted (prevention of blood and body fluid transmission).
Which maternal behavior is the practical nurse (PN) most likely to see when a new mother receives her infant for the first time? A) She eagerly undresses the infant and examines the infant completely. B) She receives the infant and traces the infant's profile with her fingertips. C) She reaches and cuddles the infant to her own body. D) She reaches but hesitates for the nurse's encouragement.
B) She receives the infant and traces the infant's profile with her fingerstips Rationale: Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during the first visit with the newborn, which may be at delivery or later.
The practical nurse caring for a laboring client encourages her to void at least q2h and records each time the client empties her bladder. What is the rationale for implementing this nursing intervention? A) emptying the bladder during delivery is difficult because of the position of the presenting fetal part B) an over-distended bladder could be traumatized during labor and could prolong the progress of labor C) urine specimens for glucose and protein must be obtained at certain intervals throughout labor D) frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection
B) an over-distended bladder could be traumatized during labor and could prolong the progress of labor Rationale: A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor. Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the dissent of the fetus.
The findings of maternal triple screen test indicates that an 18 week primigravida has an elevated serum alpha-fetoprotein level. Which information is best for the practical nurse to provide? A) The babies father should be present for discussion of these findings B) elevation of any part of this test may indicate the need for further studies C) The possibility of a birth defect is higher when these values are elevated D) this test should be performed later in pregnancy to determine its significance
B) elevation of any part of this test may indicate the need for further studies Rationale: A maternal triple screen test measures the serum levels of AFP, human chorionic gonadotropin (hCG), and maternal estriol, and it is performed between 15 and 21 weeks gestation to identify serum levels associated with down syndrome, other chromosomal defects, or neural tube defect, such as spina bifida. The client should be prepared for further testing based on the elevated AFP levels.
As part of the preoperative plan of care for a client who is scheduled for a repeat cesarean section, the practical nurse plans to administer the nonparticulate antacid sodium citrate by mouth. What is the purpose of administering this drug preoperatively? A) prevent postoperative nausea and vomiting B) raise the gastric pH to above 2.5 C) improve gastric motility D) decrease the risk of aspiration
B) raise the gastric pH to above 2.5 Rationale: sodium citrate is prescribed to increase the pH of gastric secretions and make them more alkaline so that if the client should vomit and aspirate, the chance of pneumonitis occurring is decreased.
What pulse is used to determine the presence of a pulse in the infant during cardiopulmonary resuscitation?
Brachial pulse
A client at 30 weeks gestation is on bed rest at home because of an increased blood pressure. The home health nurse has taught her how to take her own blood pressure and the parameters used to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion and headache, which information is best for the practical nurse to provide? A) "Lie on your left side and call an ambulance to take you to the emergency room immediately." B) "Taken an antacid and call back if the pain has not subsided within 1 hour after taking the antacid." C) "Take your blood pressure, and if it has significantly increased, go to the hospital immediately." D) "Drink a carbonated drink to help with belching, and call back if the indigestion has not subsided within an hour."
C) "Take your blood pressure, and if it has significantly increased, go to the hospital immediately." Rationale: obtaining a blood pressure reading is the best instruction. An elevated blood pressure, systolicly increased by 30 mmHG or diastolicly by 15 mmHG, is a sign of pregnancy induced hypertension, and headache and epigastric pain can be signs of an impending seizure (eclampsia).
A new mother has delivered her first baby vaginally and says to the practical nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the PN is best? A) "This is not an unusual shaped head, especially for a first baby." B) "It may look odd, but newborn babies are often born with heads like that." C) "That is normal. The head will return to a round shape within 7 to 10 days." D) "Your pelvis was too small, so the head had to adjust to the birth canal."
C) "That is normal. The head will return to a round shape within 7 to 10 days." Rationale: The best response is the one that reassures the mother that this is normal in the newborn and provides correct information regarding the return to a "normal" shape of the molded neonates head after a vaginal delivery.
When a client who delivered an 8-pound, 12-ounce infant 6 hours earlier is ambulating to the bathroom for the second time since delivery, the practical nurse (PN) observes blood running down her leg. What action should the PN take? A) Escort the client to the toilet and assess the perineal pad. B) Guide the client to floor and call for additional help. C) Assist the client back to bed and check her fundus. D) Place the client in a chair and take her blood pressure.
C) Assist the client back to bed and check her fundus. Rationale: The client who delivers a large-for-gestational age (LGA) infant is at risk for postpartum hemorrhage because of uterine atony. The nurse should assist the client to bed and assess the consistency of the fundus, which if boggy or displaced from the midline can predispose the client to bleeding.
A newborn infant is brought to the nursery from the birthing suite. The practical nurse (PN) notices that the infant is breathing satisfactorily but appears dusky. What action should the PN take first? A) Notify the pediatrician immediately. B) Suction the infant's nares and then the oral cavity. C) Check the infant's oxygen saturation rate. D) Position the infant on the right side.
C) Check the infant's oxygen saturation rate. Rationale: When possible, the PN should first obtain measurable objective data; an oxygen saturation rate provides such information.
The practical nurse is teaching a primigravida about breastfeeding. Which finding requires follow-up? The client: A) Wears push-up bras because of small breasts. B) Plans to enroll in an exercise class to regain her figure. C) Drinks one or two beers each evening to relax. D) Uses warm water, but no soap, to wash her nipples.
C) Drinks one or two beers each evening to relax Rationale: Alcohol of all kinds (C) should be avoided while breastfeeding, because it can be transferred through the breast milk to the infant and can cause CNS depression in the infant.
A new father asks the practical nurse (PN) why ointment is instilled into the eyes of his newborn infant. Which infection should the PN identify when describing the purpose of this treatment? A) Herpes B) Staphylococcus organisms C) Gonorrhea D) Syphilis
C) Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia.
A 25-year-old client has a positive pregnancy test. One year earlier she had a spontaneous abortion at 3 months' gestation. What is the correct description of this client that the practical nurse (PN) should document in the medical record? A) Gravida 1, para 0 B) Gravida 1, para 1 C) Gravida 2, para 0 D) Gravida 2, para 1
C) Gravida 2, para 0 Rationale: This is the client's second pregnancy or second "gravid" event, so (C) is correct. The spontaneous abortion occurred at 3 months' gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks' gestation or beyond.
A primigravida is 24 hours postdelivery by cesarean section and is using a patient-controlled analgesia (PCA) pump for pain control. She is NPO except for ice chips, is now complaining of nausea and bloating, and has hypoactive bowel sounds. She states that she is too weak to breastfeed her infant because she has not had anything to eat. Which nursing diagnosis has the highest priority? A) Altered nutrition, less than body requirements for lactation B) Alteration in comfort related to nausea and abdominal distention C) Impaired bowel motility related to pain medication and immobility D) Fatigue related to cesarean delivery and physical care demands of infant
C) Impaired bowel motility related to pain medication and immobility Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.
Which parental behavior is a warning to the practical nurse that negative bonding is likely to be occurring between parents and a newborn infant? A) Parents call the infant by name. B) Parents hold the infant out away from the body so that the infant's face can be seen. C) Parents leave the newborn infant wrapped in blankets. D) Parents give immediate attention to hunger and wet diapers.
C) Parents leave the newborn infant wrapped in blankets. Rationale: Attachment/bonding theory indicates that parents have an extreme interest in visualizing every part of the newborn in a head to toe examination and exploration process. Leaving the infant wrapped could indicate negative bonding.
Following a vaginal delivery, a postpartum client complains of severe cramping after breastfeeding her newborn. Which explanation describes the most likely reason for the client's pain? A) A retained placenta B) Problems with the process of involution C) The release of oxytocin hormone D) A possible ileus
C) The release of oxytocin hormone Rationale: During breastfeeding, oxytocin is released and will cause uterine contractions and cramping (C).
Before discharge, what information should the practical nurse give to parents regarding the newborn's umbilical cord care at home? A) wash the cord frequently with mild soap and water B) Cover the cord with a sterile dressing C) allow the cord to air dry as much as possible D) apply baby lotion after the baby's daily bath
C) allow the cord to air dry as much as possible Rationale: recent studies indicate that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process
When should the practical nurse encouraged a laboring client to begin pushing? A) at complete cervical effacement B) when the client describes the need to have a bowel movement C) at complete cervical dilation D) upon palpation of an interior or posterior lip of the cervix
C) at complete cervical dilation Rationale: pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never completely dilate, necessitating an operative delivery.
A client at 30 weeks gestation is complaining of pressure over the pubic area. At the clients admission to the antepartum unit for observation, vaginal examination shows that her cervix is closed, thick, and high. The fetal monitor reveals irregular contractions and underlying uterine irritability. Based on this information, which intervention should the practical nurse implement first? A) provide oral hydration B) encourage ambulation to stop contractions C) collect a specimen for urinalysis D) place the client on strict bed rest
C) collect a specimen for urine analysis Rationale: obtaining a urine analysis should be done first, because preterm clients with uterine irritability and contractions are often suffering from a urinary track infection and this should be ruled out first.
The total bilirubin level of a 36 hour, breast-feeding newborn is 14 mg/dL. Based on this finding, which intervention should the practical nurse implement? A) provide phototherapy for 30 minutes q8h B) Feed the newborn with sterile water hourly C) encourage the mother to breast-feed frequently D) assess the newborns blood glucose level
C) encourage the mother to breast feed frequently Rationale: breast milk provides calories and enhances G.I. motility, which will assist the bowel in eliminating bilirubin. The total bilirubin level is 6 to 12 mg/dL after day one of life. The infants bilirubin level is beginning to climb, and the infant should be monitored to prevent further complications.
A new mother is having trouble breast-feeding her newborn son. He's making frantic rooting motions and will not grasp the nipple. Which intervention should the practical nurse implement? A) encourage frequent use of a pacifier so that the infant becomes accustomed to sucking B) hold the infants head firmly against the breast until he latches onto the nipple C) encourage the mother to stop feeding for a few minutes and comfort the infant D) provide formula for the infant until he becomes calm and then offer the breast again
C) encourage the mother to stop feeding for a few minutes and comfort the infant Rationale: the infant is becoming frustrated and so is the mother; both need a timeout. The mother should be encouraged to comfort the infant and to relax herself. After such a timeout, breast-feeding is often more successful.
20 minutes after a continuous epidural anesthetic is administered, a laboring clients blood pressure drops from 120/80 to 90/60 mmHG. What action should the practical nurse take immediately? A) notify the registered nurse or anesthesiologist B) continue to assess the blood-pressure q5 minutes C) place the client in a lateral position D) turn off the continuous epidural
C) place the client in a lateral position Rationale: placing a client in the lateral position and placing a pillow or wedge under one hip will deflect the uterus
A pregnant client is being discharged after presenting to the labor and delivery unit in false labor. The nurse explains to the client the signs of true labor. Which statement made by the client indicates that further teaching is required? A) "My contractions will not go away if I walk around." B) "My contractions will get stronger and closer together." C) "My contractions may feel like really bad menstrual cramps." D) "My contractions will be irregular and I will feel them in my abdomen."
D) "My contractions will be irregular and I will feel them in my abdomen." Rationale: false labor contractions are irregular, non-progressing, and usually felt in the abdomen or groin.
A client comes to the OB clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the practical nurse (PN), "I'm having second thoughts about wanting to have this baby." Which response is best for the PN to make? A) "It's normal to feel ambivalent about a pregnancy when you are not feeling well." B) "I think you should discuss these feelings with your health care provider." C) "How does the father of your child feel about your having this baby?" D) "Tell me about these second thoughts you are having about this pregnancy."
D) "Tell me about these second thoughts you are having about this pregnancy." Rationale: Although ambivalence is normal during the first trimester, is the best nursing response at this time. It is reflective and keeps the lines of communication open.
What nursing intervention is of greatest benefit in preventing postpartum thrombophlebitis? A) Apply supportive stockings bilaterally. B) Place moist heat to varicose veins. C) Complete a focused cardiac assessment. D) Encourage early ambulation after delivery
D) Encourage early ambulation after delivery Rationale: Early ambulation increases venous return and prevents thrombophlebitis. Clotting factors are normally elevated in the postpartum period to heal the placental site, thereby predisposing clients to thrombus formation
Just after delivery, a new mother tells the practical nurse (PN), "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the PN implement first? A) Assess the husband's feelings about his wife's decision to breastfeed their baby. B) Ask the client to describe why she was unsuccessful with breastfeeding her last child. C) Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D) Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D) Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.
The practical nurse (PN) is reviewing characteristics of the newborn and is sharing common growth and development milestones with new parents when they ask, "When will the soft spots close?" The PN should respond that they can expect the infant's fontanels to close during what age span? A) The anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B) The anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C) The anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D) The anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
D) The anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month (D).
And off-duty practical nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A) use thread to tie off the umbilical cord B) provide as much privacy as possible for the woman C) reassure the husband and try to keep him calm D) put the newborn to the breast
D) put the newborn to the breast Rationale: putting the newborn to the breast well help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority.
