Exam 4 Practice Questions P2

A woman in her sixth month of pregnancy comes in for her first prenatal examination. She complains today of headache and abdominal pain of several months' duration. She appears somewhat hurried or nervous. What questions would the nurse ask next? "Do you have a family history of thyroid disease?" "Have you been eating properly and taking a prenatal vitamin?" "Do you feel safe at home?" "How much activity have you been able to fit into your schedule?"

"Do you feel safe at home?" Explanation: All these questions are important when interviewing a pregnant woman. This picture may make you think of social problems such as domestic violence, substance abuse, or both. Asking more directed questions in these areas may be fruitful.

A client who is 28 weeks' gestation with Rh-negative blood comes to the clinic for her first prenatal appointment. Which of the following statements from the client would require further action from the nurse? "I do not know who the father of my baby is." "I have been regularly exercising." "I have been watching my weight; I've only gained 10 lbs." "I feel nauseated at times, but dry crackers seem to help.

"I do not know who the father of my baby is." Explanation: Women who are Rh-negative need to receive Rho(D) immune globulin if they do not know the father of the child's blood type. RhoGAM is administered at 28 weeks' gestation, with antepartum testing, such as amniocentesis or chorionic villi sampling, to prevent isoimmunization. The fact that the client has been exercising and watching weight gain are not causes for concern. Feeling nauseated at times is normal during pregnancy.

Which statement by the pregnant woman shows an understanding that she should avoid teratogens in the first trimester? "It's okay for me to continue taking my tetracycline for my acne." "I am going to have an x-ray this week. My neck is bothering me." "One or two glasses of wine at night won't hurt. Wine helps relax me." "I have to call my doctor to switch me from lithium to another drug for my bipolar disorder."

"I have to call my doctor to switch me from lithium to another drug for my bipolar disorder." Explanation: It is very important for women to avoid teratogens during the first-trimester period (weeks 2 to 8 after conception), because all major fetal organs are formed. Lithium, tetracycline, alcohol, and exposure to radiation all are considered teratogens. The only statement that reflects an understanding is Option D.

A client who is being seen at her 14-week gestation visit reports having increased nasal congestion and occasional nose bleeds. How should the nurse respond? "Nasal stuffiness is normal but you should not be having nosebleeds." "We will need to perform a focused assessment and obtain some blood work." "These symptoms are common during pregnancy due to increased estrogen levels." "Sometimes during pregnancy, blood can become very thin, causing abnormal bleeding."

"These symptoms are common during pregnancy due to increased estrogen levels." Explanation: Nasal "stuffiness" and nose bleeds (epistaxis) are common during pregnancy due to estrogen-induced edema and vascular congestion of the nasal mucosa and sinuses. The nurse could perform a focused assessment and obtain blood work, but it is not required because these are common occurrences during pregnancy. During pregnancy hematocrit increases, making the blood thicker not thinner.

A new mother asks the nurse, "What are those small white spots on my baby's nose?" Which response by the nurse would be most appropriate? "Those are small glands that look like whiteheads but will disappear soon." "Those white spots are lesions containing pus and are caused by a minor skin infection." "Newborns retain sweat, which causes those white bumps on their skin." "Often newborns have a rash of this type, which fades in a few days."

"Those are small glands that look like whiteheads but will disappear soon." Explanation: The nurse would respond by explaining that the white spots are milia, pinpoint, pearly white spots found commonly on the nose, forehead, or face, the result of sebaceous material retained within sebaceous glands. They usually disappear. They do not indicate infection, rash, or retained sweat. The sweat glands stay small and nonfunctional until puberty.

A client who is in her first trimester states, "I've always been a fairly inactive person, but I'm determined to start going to exercise classes every day so my baby's as healthy as possible." What is the nurse's best response to the client's statement? "Usually, your doctor will recommend against starting brand new exercise programs while you're pregnant." "Good for you. Regular physical activity tends to make labor and delivery go much smoother." "That's an excellent idea, and it really reduces your risk of developing high blood sugar during pregnancy." "You just need to remember to start exercising at a slow pace to avoid putting stress on your baby."

"Usually, your doctor will recommend against starting brand new exercise programs while you're pregnant." Explanation: Exercise is beneficial, but women should be cautioned not to start new forms of exercise during pregnancy. The statements, "Good for you. Regular physical activity tends to make labor and delivery go much smoother," "That's an excellent idea, and it really reduces your risk of developing high blood sugar during pregnancy," and "You just need to remember to start exercising at a slow pace to avoid putting stress on your baby," do not address the client's knowledge deficiency related to starting new forms of exercise during pregnancy.

The 37-week primigravida states, "I think I'm going into labor." The nurse determines the contractions last approximately 20 seconds and occur every 20 to 30 minutes. Which is the best response by the nurse? "You are experiencing Braxton Hicks contractions." "You need to prepare for a Cesarean delivery." "We need to get you to the labor and delivery unit now." "You are beginning the very early stage of labor."

"You are experiencing Braxton Hicks contractions." Explanation: Braxton Hicks contractions are usually irregular in frequency and duration with fewer than five in 1 hour. While the contractions can be painful, they usually last less than 30 seconds and are common in the third trimester for a primigravida.

While caring for a pregnant client at 8 weeks' gestation, the client asks the nurse, "When can you hear the baby's heartbeat?" The nurse should instruct the client that when a Doppler device is used, the earliest time when the fetal heart rate can be heard is the gestational age of 10 weeks. 14 weeks. 18 weeks. 22 weeks.

10 weeks. Explanation: A fetal Doppler ultrasound device can be used after 10-12 weeks' gestation to hear the fetal heartbeat.

The nurse is assessing a 1-year-old infant who weighed 3.6 kg (8 lb) at birth. When the nurse prepares to weigh the infant, the nurse anticipates that this infant should weigh approximately 7.2 kg (16 lb). 9.07 kg (20 lb). 10.8 kg (24 lb). 12.7 kg (28 lb).

10.8 kg (24 lb). Explanation: Deviation from the wide range of normal weights is abnormal. x3

A 32-year-old attorney comes to the office for her second prenatal visit. She has had two previous pregnancies with uneventful prenatal care and vaginal births. Her only problem was that with each pregnancy she gained 23 kg and had difficulty losing the weight afterwards. She has no complaints today. The client's chart states that she is currently 10 weeks pregnant and that her prenatal weight was 59 kg. Her weight today is 60.9 kg. Her height is 1.66 m (5'4"), giving her a BMI of 22. Her blood pressure, pulse, and urine tests are unremarkable. The fetal heart tone is difficult to find but is located and is 150. While giving first-trimester education, the nurse tells the client how much weight she is expected to gain during pregnancy. How much weight should the nurse tell the client? Less than 7 kg 7 to 11.5 kg 11.5 to 16 kg 12.5 to 18 kg

11.5 to 16 kg Explanation: This is the appropriate amount of weight gain for a person with a normal BMI (20 to 27).

A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled immunizations. The nurse should anticipate that the infant's resting heart rate will be nearest to what value? 80 beats per minute 100 beats per minute 120 beats per minute 140 beats per minute

120 beats per minute Explanation: Heart rate decreases as infants age, with a normal heart rate of 120 to 160 at birth and declining to approximately 120 at 6 months of age and down to 110 from 6 months to 1 year old.

The clinic nurse is assessing a client who is pregnant at 18 weeks' gestation. The nurse is obtaining a fetal heart rate using Doppler ultrasound. What fetal heart rate represents an expected finding? 90 beats per minute 130 beats per minute 175 beats per minute 225 beats per minute

130 beats per minute Explanation: Fetal heart rate ranges from 120 to 160 beats/min.

24-year-old childcare worker comes to the clinic for her first prenatal visit. She cannot remember when her last period was but thinks it was between 2 and 5 months ago. When she began gaining weight and feeling "odd" she did a home pregnancy test, which was positive. She states she felt fetal movements about 1 week ago. She has had no nausea, vomiting, fatigue, or fevers. Past medical history is remarkable for irregular periods. She has been dating the same man for 1 year and says they did not use condoms. Examination reveals an overweight young woman who appears her stated age. Head, eyes, ears, nose, throat, neck, thyroid, cardiac, and pulmonary examinations are unremarkable. The client's abdomen is nontender with normal bowel sounds, and the gravid uterus is palpated to the level of the umbilicus. Fetal tones are easily found with Doptone; with the fetoscope a faint heart rate of 140 is audible. By speculum examination the cervix is bluish; by bimanual examination the cervix is soft. Pap smear, cultures, and blood work are pending. The nurse gives the client her due date and how far along she is based on clinical findings. An obstetric ultrasound to confirm her dates is ordered. Based only on the clinical examination findings, how many weeks pregnant did the nurse tell this client she was? 6 to 8 weeks 12 to 14 weeks 18 to 20 weeks 24 to 26 weeks

18 to 20 weeks Explanation: Fetal tones can be easily found with Doptone and faintly auscultated with the fetoscope. The uterus is usually at the level of the umbilicus at 20 weeks. First-time mothers usually don't feel fetal movement until 20 to 24 week

A 24-year-old childcare worker comes to the clinic for her first prenatal visit. She cannot remember when her last period was but thinks it was between 2 and 5 months ago. When she began gaining weight and feeling "odd" she did a home pregnancy test, which was positive. She states she felt fetal movements about 1 week ago. She has had no nausea, vomiting, fatigue, or fevers. Past medical history is remarkable for irregular periods. She has been dating the same man for 1 year and says they did not use condoms. Examination reveals an overweight young woman who appears her stated age. Head, eyes, ears, nose, throat, neck, thyroid, cardiac, and pulmonary examinations are unremarkable. The client's abdomen is nontender with normal bowel sounds, and the gravid uterus is palpated to the level of the umbilicus. Fetal tones are easily found with Doptone; with the fetoscope a faint heart rate of 140 is audible. By speculum examination the cervix is bluish; by bimanual examination the cervix is soft. Pap smear, cultures, and blood work are pending. The nurse gives the client her due date and how far along she is based on clinical findings. An obstetric ultrasound to confirm her dates is ordered. Based only on the clinical examination findings, how many weeks pregnant did the nurse tell this client she was? 6 to 8 weeks 12 to 14 weeks 18 to 20 weeks 24 to 26 weeks

18 to 20 weeks Explanation: Fetal tones can be easily found with Doptone and faintly auscultated with the fetoscope. The uterus is usually at the level of the umbilicus at 20 weeks. First-time mothers usually don't feel fetal movement until 20 to 24 weeks.

A pregnant woman should drink at least 0.5 L/day of water 1 L/day of water 1.5 L/day of water 2 L/day of water

2 L/day of water Explanation: Increased urination in pregnancy is common, as a result of the relaxation of the urinary system due to increased progesterone. This is one reason why it is important for the woman to drink 2 L/day of water.

A client comes to the clinic for a scheduled prenatal appointment. The nurse measures the fundal height and determines it is at the umbilicus. The nurse documents the client is how many weeks' pregnant based on fundal height? 6 12 20 24

20 Explanation: According to McDonald's rule, at 20 weeks' gestation, the fundus should be at the level of the umbilicus. After 20 weeks the fundal height should equal the number of weeks pregnant (e.g., at 25 weeks' gestation, the fundal height should measure 25 cm). The fundus grows about 1 cm/week. All other options (that is, 6 weeks, 12 weeks, and 24 weeks) are incorrect.

A pregnant client of normal weight is concerned about excessive weight gain during her pregnancy. She states, "I don't want to get fat!" The nurse should inform her that she can expect to gain how much weight during her pregnancy? 20 to 25 pounds 25 to 30 pounds 15 to 20 pounds 35 to 40 pounds

25 to 30 pounds Explanation: A simple rule of thumb for a woman of normal pre-pregnant weight is that she will gain about 10 pounds by 20 weeks and about 1 lb/week for the remaining 20 weeks, for a total of 25 to 30 pounds.

The nurse is preparing to measure the head circumference of a newborn. In a healthy newborn, the nurse should expect the circumference of the infant's head to be within what range? 33 to 35.5 cm 35 to 37.5 cm 37 to 39.5 cm 39 to 41.5 cm

33 to 35.5 cm Explanation: Newborn head circumference normally is between 33 and 35.5 cm. A circumference outside this range would be considered abnormal and a cause for concern, possibly suggesting microcephaly, improper brain growth, premature closing of the sutures, intrauterine infection, or chromosomal defect.

A nurse obtains Apgar scores on a newborn at 1 minute after birth. When should the nurse perform the next Apgar score? 2 minutes 5 minutes 10 minutes every minute for 5 minutes

5 minutes Explanation: Apgar scores are obtained at 1 minute after birth and again at 5 minutes after birth to determine the need for medical care. A score of 0 to 3 indicates a prompt need for resuscitation, 4 to 6 the newborn may need some assistance for breathing, and 7 to 10 the child is in excellent condition and no medical care is required.

The prenatal client complains of increased thirst, hunger, and urination. Which laboratory test does the nurse expect to be ordered? 50-gram glucose challenge Group B streptococcus Iron and electrolytes Complete blood count

50-gram glucose challenge Explanation: Clinical manifestations of increased thirst, hunger, and urination are suggestive of gestational diabetes in the prenatal client. A 50-gram glucose challenge test will evaluate how well glucose is metabolized. Prenatal clients with urine cultures for Group B Streptococcus are at risk for transferring the infection to their fetus. A complete blood count identifies anemia, thalassemias, thrombocytopenia, and leukocytosis. Iron deficiency anemia is common with pregnancy, and electrolyte abnormalities may occur due to vomiting associated with morning sickness.

A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range? 3 to 5 5 to 7 7 to 10 11 to 13

7 to 10 Explanation: The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside the womb. The newborn receives a score of 0 to 2 in each of 5 areas for a possible total score of 10. The score is calculated at 1 min and again at 5 min of life. Score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment. This makes the other options incorrect.

Which prenatal client has the greatest risk of delivering a baby with a defect? A 6-week pregnant woman who takes lithium (Eskalith) daily for bipolar disease A 9-week pregnant woman who received the rubella vaccine four years ago A 12-week pregnant woman taking penicillin following a tooth extraction yesterday. A 4-week pregnant woman who had a glass of wine to celebrate her wedding anniversary.

A 6-week pregnant woman who takes lithium (Eskalith) daily for bipolar disease Explanation: Lithium should not be taken during the first 3 months of pregnancy, as it is associated with heart valve defects. A woman who received the rubella vaccine four years ago or is taking penicillin is not at risk of delivering a baby with a defect. Alcohol can be a risk factor if consumed in excess; however, a woman who had a glass of wine to celebrate her wedding anniversary is probably not at risk.

A client at 26 weeks' gestation appears at the clinic for her first prenatal visit. During the health interview, she states that she has been a habitual cocaine user. The nurse understands that this client is at risk for what complication? Abruptio placenta Thrombophlebitis Placenta previa Gestational diabetes

Abruptio placenta Explanation: A history of cocaine use has a higher rate of spontaneous abortions and abruptio placentae. Thrombophlebitis, placenta previa, and gestational diabetes are not related to cocaine use.

Which child should the pediatric nurse suspect of having a developmental delay? A 5-month-old who does not sit unsupported An 11-month-old who does not pull himself to a standing position A 3-month-old who cannot grasp an object voluntarily A 12-month-old who cannot build a tower of eight blocks

An 11-month-old who does not pull himself to a standing position Explanation: By 9 months of age, an infant can pull to stand. Sitting unsupported occurs by 6 to 7 months. A 5-month-old can grasp voluntarily, and a 12-month-old will attempt to build a tower of two blocks.

A woman who recently found out she was pregnant is asking what day her baby is due. The first day of her last menstrual period was July 12, 2014. When is she due according to Naegele's Rule? April 12, 2015 April 17, 2015 April 19, 2015 April 26, 2015

April 19, 2015 Explanation: Due date may be estimated by using Naegele's Rule, which states that subtract 3 months from the first day of the LMP and add 7 days to the result. Thus, a woman whose LMP began July 12, 2014 would have an EDB of April 19, 2015.

The nurse assesses the respirations of a 2-week-old infant and identifies periods of apnea. What should the nurse do next? Assess the apical heart rate. Percuss the lungs for consolidation. Auscultate the lungs for adventitious sounds. Inspect the shape of the thorax.

Assess the apical heart rate. Explanation: Periods of apnea lasting longer than 15 seconds and accompanied by bradycardia may indicate cardiovascular or central nervous system disease. Brief apneic periods not accompanied by bradycardia are normal in young infants. Therefore, periods of apnea alone would not prompt the nurse to percuss the lungs for consolidation, auscultate the lungs for adventitious sounds, or inspect the shape of the thorax.

A client at 32 weeks' gestation, who has had regular prenatal care, is found to have gained 6 pounds in 1 week. Which of the following would be most appropriate for the nurse to do next? Ask for 24-hour diet recall. Assess the legs for edema. Collect a urine culture. Check fundal height.

Assess the legs for edema. Explanation: A sudden gain exceeding 5 pounds a week may be associated with pregnancy-induced hypertension and fluid retention. Therefore the nurse would assess the client's legs for edema. Assessing the client's diet may be appropriate if there are no other indications of problems occurring. A sudden weight gain is unrelated to a urinary tract infection, which would indicate the need for a urine culture. Checking fundal height is done regardless of the client's weight.

A nurse at the health care facility assesses a client in the 20th week of gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client? At the top of the symphysis pubis Halfway between the symphysis pubis and the umbilicus At the level of the umbilicus At the xiphoid process

At the level of the umbilicus Explanation: In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 and 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy, the fundus should reach the xiphoid process.

Which of the following changes in vital signs is expected in pregnant women? Pulse decreases. Respirations increase. Blood pressure decreases. Temperature decreases.

Blood pressure decreases. Explanation: Pulse and temperature often increase, while respirations are usually unchanged in healthy pregnant women. It is common for blood pressure to decrease during pregnancy.

The nurse is preparing to perform Leopold's maneuvers. During the first maneuver, the nurse palpates a soft mass in the upper quadrant of the abdomen. The nurse interprets this as which fetal part? Back Head Buttocks Feet

Buttocks Explanation: On the first maneuver, the soft mass palpated in the upper quadrant would most likely be the fetal buttocks. The head would feel round and hard. The back would be smooth, and the fetal fists and feet would feel nodular and are only noted with the second maneuver.

Increased pigmentation on the face of some pregnant women is called: Nigra Melanotropin Striae Chloasma

Chloasma Explanation: Chloasma, or "mask of pregnancy," is a blotchy brown discoloration on the face. In some women, a darkened line up the abdomen appears, which is called linea nigra. Striae are "stretch marks," while melanotropin is the hormone responsible for chloasma.

A nurse assesses the pulses of an infant and notes that the femoral pulses are weak. What health problem should the nurse suspect? Right ventricular enlargement Sinus arrhythmia Coarctation of the aorta Patent ductus arteriosus

Coarctation of the aorta Explanation: Weakness of absence of femoral pulses may indicate coarctation of the aorta. Bounding pulses would suggest patent ductus arteriosus. Right ventricular enlargement may be noted by a systolic heave. Sinus arrhythmia is not associated with this finding.

A nurse assesses a primigravida client in the eighth week of gestation. The client reports nausea and vomiting in the mornings. The client expresses concerns about hormonal changes that would affect her physical appearance. Which client concern should the nurse assess first? Deficient fluid volume Disturbed body image knowledge deficit Slow weight gain

Deficient fluid volume Explanation: The nurse should identify deficient fluid volume as a risk that needs immediate attention. The client may be at risk for hyperemesis gravidarum if she is dehydrated. Disturbed body image, deficient knowledge, or slow weight gain are not concerns that need immediate attention. The nurse attends to the client's concerns regarding disturbed body image and deficient knowledge by preparing a teaching plan with regard to exercise and hormonal changes during pregnancy. The nurse should prepare a diet plan that would help the client to receive adequate nutrition and achieve the desired weight gain.

A pregnant woman is concerned about the recent onset of a midline swelling that is soft and nontender. What does this represent? Linea nigra Chadwick's sign Round ligament pain Diastasis recti

Diastasis recti Explanation: In advanced pregnancy muscle tone diminishes, which may aid in the separation of the rectus abdominis muscles. This benign finding does not usually cause other symptoms. The nurse may palpate the fetus well through this opening. Linea nigra is a hyperpigmentation along the midline. Chadwick's sign is the bluish tinge to the cervix and vaginal walls seen early in pregnancy, and round ligament pain occurs as the uterus enlarges. This discomfort is usually found in the right more often than the left.

The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate? Refer the client for cardiac evaluation. Notify the physician immediately. Inquire if the client has chest pain. Document and continue to follow at future visits.

Document and continue to follow at future visits. Explanation: Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal. Because the finding is normal, referring the client for cardiac evaluation, notifying the physician immediately, and inquiring if the client has chest pain are not the most appropriate actions.

A nurse performs a focused cardiac assessment on a neonate 8 hours after birth. The nurse documents the following findings: systolic murmur, pulse rate of 140 beats/min. What action should the nurse take? Notify the health care provider of the high heart rate. Notify the health care provider of the murmur. Reassess the neonate in 4 hours. Document normal findings.

Document normal findings. Explanation: A systolic murmur may be heard in a neonate for up to 24 to 48 hours while adapting from intrauterine to extrauterine life. A normal pulse rate for a neonate is 120 to 160 beats/min. Because the murmur and the heart rate are normal findings, the health care provider does not need to be notified. The nurse may reassess the client in 4 hours, but this is not necessary. The nurse should document the normal findings.

A nurse performs an Apgar assessment on a newborn at 1 minute with a score of 7 and at 5 minutes with a score of 10. What action should the nurse take? Provide some assistance for breathing. Provide prompt resuscitation. Document normal findings. Reassess in 5 minutes.

Document normal findings. Explanation: Apgar is used immediately after birth at 1 minute and 5-minute intervals to determine if medical care is needed. A score of 7 to 10 means the newborn is in excellent condition. A score of 4 to 6 indicates a need for assistance with breathing. A score of 0 to 3 indicates a need for prompt resuscitation. Assistance for breathing or resuscitation is not required in this case because these are normal findings for a newborn. Reassessing in 5 minutes may be necessary if there are changes in the neonate's condition, but this is not the best action for the nurse to take at this time.

The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first? Apply oxygen Document the heart rate Notify the health care provider Increase the temperature in the incubator

Document the heart rate Explanation: A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.

The nurse is palpating a pregnant client's left and right adnexa. The presence of a palpable mass should prompt the nurse to refer the client promptly for what problem? Abruptio placentae Placenta previa Ectopic pregnancy Incompetent cervix

Ectopic pregnancy Explanation: Adnexal masses may indicate ectopic pregnancy. Adnexal masses are not suggestive of placenta previa, abruption, or an incompetent cervix.

The nurse assesses the skin of a 2-week-old infant. For which finding should the nurse notify the health care provider? Port-wine stain at the base of the neck Telangiectatic nevi over the left shoulder Eight hyperpigmented macules over both legs Small birth mark on the back of the right upper leg

Eight hyperpigmented macules over both legs Explanation: Hyperpigmented macules are considered Café au lait spots. If more than 6 are present, it may indicate neurofibromatosis and should be reported to the health care provider. A port-wine stain, telangiectatic nevi, and birth marks are considered normal newborn skin variations.

Which of the following findings is most worrisome in Melissa, a woman in her 26th week of pregnancy? Generalized hair loss A hyperpigmented rash over the maxillary region bilaterally Nosebleeds Facial edema

Facial edema Explanation: Generalized hair loss, hyperpigmented maxillary rash (chloasma), and nosebleeds are usually benign and common in pregnancy. Facial edema after the 24th week of gestation may indicate gestational hypertension.

The nurse is assessing a pregnant client with Leopold maneuvers. Which finding should the nurse expect when completing this assessment? Head feels soft and irregular Smooth area is the fetal abdomen Fetal buttocks feel like a soft mass Round nodules are vertebral bones

Fetal buttocks feel like a soft mass Explanation: When assessing using Leopold maneuvers, the nurse should identify the fetal buttocks as being a soft mass. The head is round, firm, and ballotable. The back is a smooth area. Round nodules are the hands and feet.

The nurse is assessing the anterior fontanelle of a 4-month-old infant brought to the clinic for a well-child exam. What would the nurse expect to assess? Sunken Closed Bulging Flat

Flat Explanation: The anterior fontanelle is diamond-shaped and remains palpable until about 18 months. Normally it is open and flat, not sunken (dehydration) or bulging (increased pressure).

Which action by the nurse demonstrates the correct technique of assessing for the popliteal angle? Flex thigh on top of the abdomen Flex the elbows bilaterally up Bend wrist toward ventral forearm Lift the arm toward the opposite shoulder TAKE ANOTHER QUIZ

Flex thigh on top of the abdomen Explanation: Flexing the thigh on top of the abdomen is used to test the popliteal angle. To assess for the square window sign, the nurse should bend the newborn's wrist towards the ventral forearm until resistance is met and the angle is measured. Flexing the elbows up bilaterally is done to test arm recoil. Lifting the arm across the chest towards the opposite shoulder until resistance is met is done to elicit the Scarf sign.

A client presents to the health care clinic for her first prenatal checkup. What nutritional supplement should the nurse discuss with the client to prevent neural tube defects in the developing fetus? Vitamin E Calcium Iron Folic acid

Folic acid Explanation: Pregnant women need to consume 400µg of folic acid to help prevent neural tube defects. This can be achieved by eating fruits, vegetables, fortified cereals, or a daily supplement. Routine supplementation of all other vitamins is based solely on needs assessment. Iron supplements are recommended to prevent iron deficient anemia.

When the nurse palpates the neck of an infant, he notices crepitus at the right clavicular area. The infant also exhibits decreased movement in the right arm. Which of the following would the nurse suspect? Increased intracranial pressure Down's syndrome Foreign body aspiration Fractured clavicle

Fractured clavicle Explanation: Crepitus and decreased mobility of the arm on that side suggest a fractured clavicle. A bulging fontanelle would suggest increased intracranial pressure. A short webbed neck would suggest an anomaly such as Down's syndrome. Shift in tracheal position from midline suggest a possible foreign body aspiration.

trimester of pregnancy. She has been pregnant five times, including this time. She has three living children. Her first two children were delivered at 40 weeks' gestation. The third child was delivered at 32 weeks of gestation. She experienced a miscarriage 5 years ago. Which of the following indicates the correct way to document this client's current gravida/para status? P5G2113 G5P2113 P3G5112 G3121P5

G5P2113 Explanation: Gravida (G) is the total number of pregnancies, and should appear first. Para (P) is the number of pregnancies that have delivered at 20 weeks' gestation or greater. The four numbers that follow "P" indicate numbers of occurrences of each of the following: term gestation (delivery of pregnancy from 38 to 42 weeks' gestation), preterm gestation (delivery of pregnancy after 20 weeks and before the start of 38 weeks of gestation), abortion (spontaneous or induced termination of pregnancy before the 20th week of gestation), and living (number of living children). Thus, G5P2113 correctly indicates this client's gravida/para status.

An pregnant adult client presents to the clinic in the first trimester of her pregnancy complaining of sharp pains in the lower abdomen. The client states the sharp pains are not repetitive but she notices the pain often when changing position. What is the probable cause of the client's symptoms? Growing pains Pyelonephritis Ectopic pregnancy Possible miscarriage

Growing pains Explanation: In the first trimester, sharp pains in the lower abdomen are common. Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short (less than 5 seconds) and have a stabbing quality. Pyelonephritis is a kidney infection. Ectopic pregnancy and possible miscarriage are marked by sudden bleeding, not by the type of pains described in this scenario.

A nurse assesses a 32-year-old primigravida client with twin gestation in her second trimester. The client reports constipation from iron supplements. Which condition should the nurse assess for in this client as a result of the constipation? Gastric ulcer Hemorrhoids Thrombophlebitis Ptyalism

Hemorrhoids Explanation: The nurse should assess this client for hemorrhoids. Constipation, is a common problem during pregnancy, especially in clients who take iron supplements and hemorrhoids may develop because of the pressure on the venous structures from straining to have a bowel movement. Gastric ulcers may cause bleeding and would be a reason for taking iron supplements. Clients who are placed on bedrest during pregnancy are at a very high risk for development of thrombophlebitis. Ptyalism or excessive salivation may occur in the first trimester.

On assessing a newborn, a nurse observes a separation of the abdominal muscles. That nurse recognizes the underlying case of this condition is which of the following? Malnutrition and dehydration Immature abdominal muscles Umbilical hernia Pyloric stenosis

Immature abdominal muscles Explanation: (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance. A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. A distended abdomen may indicate pyloric stenosis. A bulge at the umbilicus suggests an umbilical hernia.

A 28-year-old primigravida client with diabetes mellitus, in her first trimester, comes to the health care clinic for a routine visit. The client reports frequent episodes of sweating, giddiness, and confusion. What should the nurse tell the client about these experiences? Tissue sensitivity to insulin increases as pregnancy advances Use of insulin needs to be reduced as pregnancy advances Increased secretion of insulin occurs in the first trimester Insulin resistance becomes minimal in the latter half of the pregnancy

Increased secretion of insulin occurs in the first trimester Explanation: Increased secretion of insulin in the maternal body in the first trimester is due to the rise in serum levels of estrogen, progesterone, and other hormones. During the second half of pregnancy, tissue sensitivity to insulin progressively decreases, producing hyperglycemia and hyperinsulinemia. Use of insulin needs to be increased not reduced as pregnancy advances. Insulin resistance becomes maximal not minimal in the latter half of the pregnancy.

A 29-year-old homemaker who is G4P3 comes to the clinic for her first prenatal examination. Her last menstrual period was 2 months ago. She has had three previous pregnancies and births with no complications. She has no medical problems and has had no surgeries. Her only current complaint is severe reflux in the mornings and evenings. Examination reveals no acute distress. Her blood pressure is 110/70 with a pulse of 88. Her respirations are 16. Head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On bimanual examination, her cervix is soft and her uterus is 10 weeks in size. Pap smear, cultures, and blood work are pending.What is the most likely cause of her reflux? Increasing prolactin level Increasing antidiuretic hormone (ADH) level Increasing progesterone level Enlarged gravid uterus

Increasing progesterone level Explanation: Progesterone lowers esophageal sphincter tone, leading to reflux and heartburn. It also relaxes tone and contraction of the ureters and bladder, increasing risk of UTI and subsequent bacteremia.

A nurse is assessing a newborn and observes the baby's skin to be cool. The newborn has cyanotic nail beds, pallor, and a temperature of 96 degrees Fahrenheit. What would be the priority nursing diagnosis for this newborn? Neonatal jaundice related to destruction of fetal hemoglobin Ineffective thermoregulation related to immaturity of neurologic and endocrine systems Ineffective adjustment to extrauterine life related to birth Ineffective immune system related to immature immune function

Ineffective thermoregulation related to immaturity of neurologic and endocrine systems Explanation: Signs of ineffective thermoregulation include cool skin, cyanotic nail beds, pallor, piloerection, temperature below normal range, and lack of shivering. Newborns have immature thermoregulation and should have their temperature monitored closely. The nurse should keep the room temperature warm and ensure that the infant's head is covered. Radiant warmers should be used immediately following birth.

A nurse is attempting to auscultate fetal heart tones after determining that the fetus is in a longitudinal lie, cephalic presentation, and left occiput anterior position. The nurse would auscultate them at which area? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant

Left lower quadrant Explanation: Fetal heart tones are best heard through the fetal back. In left occiput anterior position, the back of the fetus is in the left lower quadrant.

A client in her third trimester of pregnancy is undergoing a physical assessment. Her nurse explains that she is about to estimate what position the fetus is presently in by palpating the uterine fundus to see whether the head or buttocks is presenting. What is this procedure called? Leopold's maneuver Johnson's maneuver Non-stress test Montgomery's test

Leopold's maneuver Explanation: Leopold's maneuvers are performed to determine the position of the fetus and determine whether the fundus contains the head or the buttocks. The head moves independently of the torso but the buttocks do not.

A nurse examines a 6-month-old infant. The persistence of which reflex should the nurse recognize as abnormal? Sucking Tonic neck Plantar Moro

Moro Explanation: The persistence of the Moro (startle) reflex past 4 months of age is abnormal; may indicate a CNS injury. The sucking reflex does not disappear until 10-12 months of age. Tonic neck reflex disappears between 4-6 months of age. The plantar reflex disappears around 10 months of age.

Which of the following is a sign of moderate respiratory distress in an infant? Deep retractions Nasal flaring Restlessness Agitation

Nasal flaring Explanation: Most emergencies for the newborn involve respiratory decompensation. Signs of newborn respiratory distress include increased respiratory and heart rates, nasal flaring, and intercostal and substernal retractions. The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest). Moderate respiratory distress includes nasal flaring, retractions of the chest wall, grunting auscultated with a stethoscope, cyanosis on room air, and abnormal blood gas values. Severe distress is indicated by increasing work of breathing, deep retractions, audible grunting, and central cyanosis. Acute assessment of the infant is the same as for a small child. Restlessness and agitation are distracters for the question.

A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate? Pneumonia Normal Atelectasis Narrowing of the upper tracheobronchial tree

Normal Explanation: Breath sounds may seem louder and harsher in young children because of their thin chest walls. Diminished breath sounds suggest respiratory disorders such as pneumonia or atelectasis. Stridor (inspiratory wheeze) is a high-pitched, piercing sound that indicates a narrowing of the upper tracheobronchial tree. Expiratory wheezes indicate narrowing in the lower tracheobronchial tree.

The nurse is performing an eye assessment on a newborn and is unable to elicit a red reflex. What is the priority intervention that the nurse should do at this time? Nothing--newborns do not have a red reflex. Continue with the assessment. Notify the physician. Although of no clinical significance, document the finding on the clinical record.

Notify the physician. Explanation: The inability to elicit a red reflex from a newborn can be clinically significant. The infant should be referred to a specialist. Absence of a red reflex can indicate congenital cataracts or neuroblastoma.

Which method should a nurse use when assessing respirations in a newborn? Observe the respiratory effort for one full minute Place stethoscope over 4 intercostal space on the left Watch the chest rise and fall for each breath Auscultate for 15 seconds & multiply by 4

Observe the respiratory effort for one full minute Explanation: A nurse should observe a newborn or infant's respiratory effort for one full minute because they have periodic irregular breathing, often accompanied by apnea lasting a few seconds. Anytime a nurse finds an irregular pulse or respiratory rate, the vital sign should be assessed for a full minute to obtain an accurate rate. The pulse should be auscultated at the 4 intercostal space because the heart lays more horizontal in the chest. One full breath is an inhalation and exhalation.

During the assessment of a 2-month-old infant's reflexes, the nurse placed a finger in the baby's hand and pressed against the palm. The baby flexed all fingers to grasp the nurse's finger. How would the nurse document this finding? Plantar grasp reflex intact Moro reflex intact Support reflex intact Palmar grasp reflex intact

Palmar grasp reflex intact Explanation: Placing a finger in the baby's hand and pressing against the palm is testing for the palmar grasp reflex. A normal response is the baby flexes all fingers to grasp the nurse's finger. The Moro reflex is abruptly lowering the baby's body. The support reflex is standing the baby upright and observing for the hips, knees, and ankles to extend. The Plantar grasp reflex is touching the sole at the base of the toes and watching for the toes to curl.

A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next? Pupillary response to light Movement of extremities Palpate anterior fontanelle Head posture and control

Palpate anterior fontanelle Explanation: After observing an irregularly shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurologic assessment of the infant to assess for deficits.

The nurse is caring for a 48-hour-old newborn who has not yet passed stool. What is the best response of the nurse? Document normal findings. Perform a focused assessment. Perform an emergent assessment. Notify the health care provider.

Perform a focused assessment. Explanation: Normally a newborn passes stool within the first 24 hours of life. If a newborn has not passed stool after 48 hours of life, Hirschsprung disease should be considered. The nurse would not document the findings (not passing stool for 48 hours after birth) as normal. The nurse should perform a focused assessment of the abdomen. If the abdomen is rigid or distended and the newborn is vomiting, the nurse will need to contact the health care provider about the findings. The nurse does not need to perform an emergent assessment.

The pregnant client tells the nurse she has a history of mitral valve stenosis as a sequela of rheumatic fever. The nurse plans to closely monitor the client based on the understanding that which physiologic change in pregnancy increases this client's risk for complications? Physiologic anemia Altered carbohydrate metabolism Increased blood volume Hormonal changes

Physiologic anemia Explanation: The increase in cardiac output and maternal blood volume places a client with mitral valve disease at increased risk for complications because of the extra demand placed on the heart. Physiologic anemia is the result of the increased blood volume. Altered carbohydrate metabolism might be problematic for the client with diabetes. Hormonal changes would not play a role in increasing the woman's risk for complications in this situation.

When assessing a newborn post vaginal delivery, the nurse observe bluish colored hands and feet. What is the nurse's priority action? Call the emergency response team immediately. Place the newborn under the radiant warmer. Palpate the apical pulse at the 5th left intercostal space. Notify the healthcare provider to evaluate the newborn.

Place the newborn under the radiant warmer. Explanation: The first action of the nurse is to place the infant under the radiant warmer. The hands and feet of the newborn may appear blue at times (acrocyanosis), which is normal, especially when the newborn is cold. With warming, skin color should return to pink. If the infant does not respond with warming techniques (placing newborn under radiant heater or adding a layer of blankets), consider a congenital heart defect in the newborn. The nurse should auscultate, not palpate, the apical pulse at the 4th intercostal space. The remaining options are premature and should be implemented when assessment warrants such actions.

During the assessment of a 6 month old what finding would the nurse expect find? Posterior fontanelle is bulging Posterior fontanelle is closed Anterior fontanelle is bulging Anterior fontanelle is closed

Posterior fontanelle is closed Explanation: The posterior fontanelle usually closes around 3 months. The anterior fontanelle usually closes between 9 and 18 months. Bulging is an indication of increased intracranial pressure or hydrocephalus.

A client at her prenatal visit is found to have 1+ protein in her urine. This is suggestive of what health problem? Bladder infection Preeclampsia Pyelonephritis Eclampsia

Preeclampsia Explanation: Proteinuria 1+ or greater may indicate preeclampsia and thus requires a provider's attention.

The client has confirmation of an unruptured ectopic pregnancy. What does the nurse anticipate will be a priority intervention? Inform the client that she may always have trouble during pregnancy. Encourage the client to continue daily activities and report any pain. Prepare the client for termination of the pregnancy. Prepare for observation of the client for 48 hours.

Prepare the client for termination of the pregnancy. Explanation: Ectopic pregnancy is a pregnancy outside of the uterus, usually because the egg does not leave the fallopian tube. Confirmation of ectopic pregnancy is considered an obstetric emergency requiring hospitalization and termination of the pregnancy.

A nurse working in a day care center finds that a 9 month old has a patch of silvery, scaly, plaques. She informs the baby's mother to follow up with a family physician about the lesions. The nurse understands that these lesions are consistent with what skin disorder? Eczema Candida albicans Psoriasis Atopic dermatitis

Psoriasis Explanation: Psoriasis is a proliferative, inflammatory, autoimmune disease characterized by well-defined plaques covered by silvery scales. Eczema is thickened skin with scaling that results from irritation that follows repetitive rubbing or scratching. Candida albicans is a fungal infection usually found in the diaper area of infants. Atopic dermatitis is a rash found when an infant is exposed to an allergen.

The nurse is performing an otoscopic examination of an infant's ears. What would the nurse do? Pull the pinna forward and down. Pull the pinna up and back. Pull the pinna straight back. Pull the pinna down and back.

Pull the pinna down and back. Explanation: In infants, the external auditory canal curves upward and is short and straight. Therefore, the pinna must be pulled down and back to straighten the canal to view the tympanic membrane.

The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion? Risk for Ineffective Breastfeeding Knowledge deficit RC: Failure to thrive RC: Hip displacement

RC: Hip displacement Explanation: The priority conclusion is that the infant is at risk for complications related to hip displacement, as the findings of unequal gluteal folds and limited hip abduction indicate. The problem related to breastfeeding does not appear to be an issue of knowledge deficit, as the mother has received proper instruction. Also, risk for ineffective breastfeeding would be an inaccurate diagnosis, as ineffective breastfeeding has already occurred. Because the baby has switched to bottle feeding, however, and because there are no other adverse indications related to the child's weight gain or nutritional status, there is no failure to thrive or risk of complications thereof.

The nurse is completing the assessment of a client who is 26 weeks' pregnant. Assessment reveals a fundal height of 21 cm. How should the nurse follow up this assessment finding? Have the client reassessed for gestational diabetes. Obtain a 24-hour food recall. Refer the client due to possible intrauterine growth retardation. Order a repeat ultrasound due to possible multiple gestation.

Refer the client due to possible intrauterine growth retardation. Explanation: Uterine size should approximately equal the number of weeks of gestation. Measurements smaller than expected may indicate intrauterine growth retardation. Nutrition may contribute to this problem, but a referral is the first priority. This assessment finding is not congruent with gestational diabetes.

The nurse begins the assessment of a 1-month-old baby. What should the nurse do first when weighing this client? Remove all clothing Place paper on the scale Hold the infant over the abdomen Ask the mother to hold the head to prevent movement

Remove all clothing Explanation: An infant should be weighed naked. Paper is used when measuring length. The infant should not be held at the abdomen or the head when measuring body weight.

A pregnant client visits the clinic for the first time. The nurse should explain to the client that she will have initial routine blood tests, which include testing for ?-fetoprotein levels. chromosomal anomalies. cystic fibrosis. Rh status.

Rh status. Explanation: Explain that after the examination is complete, the client will go to the laboratory for initial prenatal blood tests including complete blood count, blood type and screen, and Rh status.

A client is 28 weeks pregnant when lab work is completed in the clinic. The client is Rh negative with a white blood cell count of 12,000 and normal platelet count. The nurse should plan for which treatment? Standard treatment for thalassemia. Infusion treatment for thrombocytopenia. RhoGAM administration. 10 day course of antibiotics.

RhoGAM administration. Explanation: Mothers with Rh negative blood are given RhoGAM at approximately 28 weeks' gestation or in cases of abdominal trauma or miscarriage. This is to prevent isoimmunization of the mother, which can endanger future pregnancies. Anemia may be treated with iron supplementation or iron-rich foods. Thalassemias may require referral to specialists because the condition poses some risks to the fetus. Patients with low-platelet levels are at risk for hemorrhage or disseminated intravascular coagulation and may not be candidates for epidurals. White blood cell (WBC) counts are usually elevated in pregnancy; they may be as high as 12,000/mm3 prenatally, and during labor they may rise as high as 30,000/mm3. WBCs in excess of these numbers suggest a potential infection.

The nurse is inspecting a pregnant client's cervix during a prenatal clinic visit. What is an expected assessment finding? Smooth cervix with a bluish tint Slightly rough cervix with dark pink coloration Pink or red cervix with small, visible nodes Smooth cervix with small amounts of creamy white discharge

Smooth cervix with a bluish tint Explanation: The client's cervix should look pink, smooth, and healthy. It may have a bluish tint during pregnancy, but should be free of nodes or discharge.

Which action by the nurse demonstrates the correct technique to assess the anus? Abduct the legs and move the knees outward Adduct the legs until the nurse's thumbs touch Assess the symmetry of the gluteal fold Spread the buttocks with gloved hands

Spread the buttocks with gloved hands Explanation: The buttocks are spread with gloved hands to examine the anus. The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia.

A pregnant client visits the clinic for the first time. The client tells the nurse that this is her first pregnancy and that she and her husband are Ashkenazi Jews and immigrated to the United States from Israel. The nurse should encourage the client to be tested for sickle cell anemia. cystic fibrosis. cerebral palsy. Tay-Sachs disease.

Tay-Sachs disease. Explanation: Certain inherited disorders occur more often in particular ethnic groups such as Tay-Sachs disease in the Ashkenazi Jewish population.

A pregnant client in her first trimester states, "I think I must be having a miscarriage. I have sharp pains in my lower abdomen sometimes!" What does the nurse understand is happening to this client? The client is having a miscarriage. The client is having hyperemesis gravidarum. The client is experiencing stretching of the round and broad ligaments. The client is experiencing an ectopic pregnancy.

The client is experiencing stretching of the round and broad ligaments. Explanation: In the first trimester of pregnancy, sharp pains in the lower abdomen are common. Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short and have a stabbing quality. They are not repetitive, but are often associated with position changes, or later fetal movements.

At what point in the pregnancy is it possible for the fetus to survive outside the womb? The end of the first trimester The end of the second trimester The end of the third trimester The end of the fourth trimester

The end of the second trimester Explanation: During the second trimester, fetal growth is significant. The fetus begins this trimester 3 inches long and weighing less than 1 oz (0.8 gm). By the end of the second trimester, the fetus is about 15 inches long and weighs more than 2 lbs (1000 gm). Major organs develop to the point that the fetus may survive with help outside the womb.

A nurse midwife is making a well-baby visit for a 5-month-old infant. The nurse determines delayed development when which of the following is observed? The infant lacks head control. The infant shows a positive Babinski response. The infant seeks comfort from the parent. The infant's respiratory rate is 40 breaths/min.

The infant lacks head control. Explanation: Infants should have head control by 4 months of age. If the infant lacks head control by 6 months, this may indicate cerebral palsy. A positive Babinski reflex (fanning of the toes) is normal up to 2 years in infants. The child seeking comfort from their parent indicates that trust versus mistrust has been achieved according to Erikson's psychosocial development theory. A respiratory rate of 40 breaths/min is normal in infants up to 12 months.

The nurse is measuring a pregnant client's fundal height during a scheduled prenatal visit. The nurse should measure with reference to what anatomical landmarks? the edge of the fundus and the umbilicus the symphysis pubis and the fundus the fundus and the abdomen the xiphoid process and the symphysis pubis

The nurse is measuring a pregnant client's fundal height during a scheduled prenatal visit. The nurse should measure with reference to what anatomical landmarks --> the symphysis pubis and the fundus Explanation: Fundal height is measured between the symphysis pubis and the fundus. The edge of the fundus and umbilicus, the fundus and the abdomen, and the xiphoid process and the symphysis pubis, are not anatomical landmarks that are used to measure a pregnant client's fundal height.

A client at 32 weeks' gestation has been placed on complete bed rest due to premature labor contractions. The nurse should prioritize assessments for which complication? Hyperglycemia Urinary tract infection Thrombophlebitis Leg cramps

Thrombophlebitis Explanation: Pregnant women are more prone to the development of thrombophlebitis because of the hypercoagulable state of pregnancy. Women placed on bed rest during pregnancy are at a very high risk for thrombophlebitis. Hyperglycemia, urinary tract infection, or leg cramps are normally unrelated to bed rest.

Which change in the breasts should a nurse recognize as a normal change associated with pregnancy? Hypopigmentation of the areola and nipples Disappearance of superficial veins Expression of colostrum in the first trimester Tingling sensations and tenderness

Tingling sensations and tenderness Explanation: Normal changes in the breasts associated with pregnancy include tingling sensations and tenderness, enlargement of the breast and nipples, hyperpigmentation of the areola and nipples, enlargement of Montgomery tubercles, prominence of superficial veins, development of striae, and expression of colostrum in the second and third trimesters.

A client in her third trimester is scheduled for a nonstress test. What is the purpose of the nonstress test for the client? To determine if the baby is Rh positive To determine if the client has pregnancy-induced hypertension To determine the well-being of the fetus To determine if the client is ready for delivery

To determine the well-being of the fetus Explanation: The purpose of the nonstress test is to determine fetal well-being. In this noninvasive test, the nurse will link the client to an electronic fetal monitor, place the tocodynamometer on the fundus to measure uterine contractions, and place the ultrasound monitor where the fetal heart can be heard to measure the fetal heart rate.

A woman is only 30 weeks pregnant, but the physician determines that the fetus must be delivered for the safety of the mother. The physician orders a glucocorticosteroid injection to be given. Why does the physician order this injection? To promote the formation of surfactant in the fetal lungs To stimulate the fetal heart rate To stimulate the mother's heart rate To help the mother breathe better while in labor

To promote the formation of surfactant in the fetal lungs Explanation: A key task of the third trimester is maturation of the fetal lungs. Growth factors in amniotic fluid promote growth and differentiation of lung tissue. With normal amniotic fluid volume, functionality of the lungs depends on their ability to form surfactant, which prevents collapse of the alveoli upon expiration. If a fetus must be delivered between 28 and 34 weeks, a glucocorticosteroid injection is given to the mother to promote the formation of surfactant.

When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex? Moro reflex Rooting reflex Palmer grasp reflex Tonic neck reflex

Tonic neck reflex Explanation: When assessing the tonic neck reflex, turn the head of the supine infant to one side. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencer position. Repeat by turning the head to the other side--the position will reverse. This reflex is strongest at 2 months and disappears by 6 months. If still present at 9 months, it may indicate neurological damage.

A woman has a positive pregnancy test and comes to the nurse with left lower quadrant pain. Bimanual examination reveals a tender mass. Which of the following is suspected? Threatened abortion Appendicitis Ovarian cyst Tubal pregnancy

Tubal pregnancy Explanation: Lower quadrant pain in a young woman could represent any of these possibilities. A positive HCG test and left, not right-sided, pain make appendicitis less likely. Presence of an extrauterine mass makes threatened abortion less likely.

Why is it important for the nurse to inquire about the client's history of sexually transmitted diseases before the client attempts to conceive? Untreated gonorrhea can delay the progression of an egg to the uterus, resulting in an ectopic pregnancy. Untreated chlamydia can suppress progesterone levels and make conception difficult. Previous history of sexually transmitted diseases can lead to uterine cancer. Previous history of sexually transmitted diseases can cause abnormal zygote development after fertilization.

Untreated gonorrhea can delay the progression of an egg to the uterus, resulting in an ectopic pregnancy. Explanation: No or delayed treatment of gonorrhea and chlamydia can cause inflammation of the fallopian tube and result in scarring, which can delay the progression of the egg to the uterus. The result can be ectopic pregnancy.

The nurse has established an expected outcome for a hospitalized newborn, "The newborn will maintain birth weight of 6 lbs 2 oz by discharge." Which nursing action can best evaluate the outcome? Weighing the infant on the same scale. Recording intravenous intake every shift. Monitoring formula intake for each meal. Determining the infant's urinary output.

Weighing the infant on the same scale. Explanation: Weighing the infant on the same scale allows the nurse to observe trends in the infant's weight. All sources of intake and output need to be recorded and can provide important information regarding fluid balance of the newborn.

Normal breathing pattern for a full-term infant may include abdominal breathing with a rate of 80 to 100 breaths/minute. chest breathing with nasal flaring of 20 to 40 breaths/minute. shallow and irregular breathing with a rate of 80 to 100 breaths/minute. abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute.

abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute. Explanation: A normal rate is 30-60 breaths/min.

A pregnant client near term is admitted to the hospital with scant vaginal bleeding, mild contractions, very firm uterus, and pain on palpation of uterus. The client tells the nurse that she uses cocaine occasionally. The nurse should assess the client for signs and symptoms of oligohydramnios. polyhydramnios. placenta previa. abruptio placentae.

abruptio placentae. Explanation: Women who use cocaine during pregnancy have a higher rate of spontaneous abortions and abruptio placentae.

One cardiac change that commonly occurs in a pregnant client is an increase in maternal blood volume by 40% to 50%. a decrease in plasma volume by 20%. physiologic hypertension that stabilizes by 24 weeks' gestation. a decrease in the heart rate of the client.

an increase in maternal blood volume by 40% to 50%. Explanation: One of the most dynamic changes is the increase in cardiac output and maternal blood volume by approximately 40% to 50%.

During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time? bulging anterior fontanelle bulging posterior fontanelle heart rate 68 beats per minute respiratory rate 70 per minute

bulging anterior fontanelle Explanation: Increased intracranial pressure produces a bulging, full anterior fontanelle and is seen when a baby cries. By age 4 months the posterior fontanelle should be closed. The average heart rate of a 4-month old should be between 80 and 180 beats per minute. The respiratory rate for this baby should be less than 50 breaths per minute.

A nurse is performing the fourth Leopold maneuver and their hands stop when resistance is met. The nurse interprets this as which of the following? fetal lie presenting part engagement position

engagement Explanation: The nurse should interpret this finding as engagement, which refers to when the fetal head has engaged into the pelvic inlet. Fetal lie refers to where the fetus is lying in relation to the mother's back. The presenting part refers to part of the fetus that is in the maternal pelvis. Fetal positions include right occiput anterior (ROA), left occiput posterior (LOP), left sacrum anterior (LSA), and so on.

The nurse is caring for a client who is 24 weeks pregnant. The client tells the nurse that she has been secreting colostrum for the past few days. The nurse should instruct the client that colostrum secretion does not normally occur until delivery of the baby. may be indicative of a problem with the breasts. is normal for some women in the second and third trimesters. may be indicative of preterm labor ensuing.

is normal for some women in the second and third trimesters. Explanation: Breast changes noted by many women include expression of colostrum in the second and third trimester.

While assessing a pregnant client at 36 weeks' gestation, the nurse observes that the client's face is edematous and she has 3+ reflexes with mild clonus. The nurse should refer the client to a physician for possible hydatidiform mole. multiple gestation. pregnancy-induced hypertension. hyperthyroidism.

pregnancy-induced hypertension. Explanation: After 20 weeks, increased BP (greater than 140/90) may be associated with pregnancy-induced hypertension.

While assessing a pregnant client at 36 weeks' gestation, the nurse observes that the client's face is edematous and she has 3+ reflexes with mild clonus. The nurse should refer the client to a physician for possible: hydatidiform mole. multiple gestation. pregnancy-induced hypertension. hyperthyroidism.

pregnancy-induced hypertension. Explanation: After 20 weeks, increased BP (greater than 140/90) may be associated with pregnancy-induced hypertension.

The nurse is assessing the abdomen of a 29-week multigravida. Which assessment finding would the nurse recognize as abnormal? pruritus gravidarum linea nigra striae gravidarum diastasis recti

pruritus gravidarum Explanation: Pruritus gravidarum, a rash with intense itching, is caused by stasis of bile salts and is considered an abnormal assessment finding. Diastasis recti (separated muscles of the abdominal wall), linea nigra (a hyperpigmented line between the symphysis pubis and the top of the fundus, and striae gravidarum (stretch marks) are normal abdominal assessment findings.

A pregnant client who is at approximately 36 weeks' gestation tells the nurse that she experiences dizziness while in bed. The nurse should instruct the client to avoid which position? side-lying. left lateral. prone. supine.

supine. Explanation: In later pregnancy, the client in the supine position may experience dizziness caused by the heavy uterus compressing the vena cava and aorta. This compression reduces cardiac r