Kaplan - Maternity Gynecology A,B,C,

A client comes to the prenatal clinic for her first visit. The nursing history reveals that the client's last menstrual period was five months ago, and the client is sure she is pregnant because she has been feeling the baby move. Whcih of the following responses by the nurse is BEST? 1. "Since you have felt the fetal movement, I am sure that you are pregnant." 2. "Lie down so that I can listen for fetal heart tones with the Doppler." 3. "We'll collect a urine specimen for testing to confirm that you are pregnant." 4. "Have you noticed feeling more fatigued lately?"

"Lie down so that I can listen for fetal heart tones with the Doppler." Auscultating fetal heart tones, visualization of fetus by ultrasound or x-ray, or fetal movement palpated by the examiner are all positive signs of pregnancy.

The nurse prepares the client for a total abdominal hysterectomy with bilateral salpino-oophorectomy due to uterine cancer. The nurse observes that the client is talking continuously and has difficulty maintain eye contact. Which response by the nurse is BEST? 1. What are your concerns about the surgery 2. Why isn't your husband here with you 3. Are you afraid that you are going to die? 4. You seem to be coping with the surgery very well

"What are your concerns about the surgery?" Client's behavior indicated that she is feeling anxious; allow client to verbalize her feelings, abdominal hysterectomy with bilateral salping-oophorectomy is removal of uterus, fallopian tubes, and ovaries; post-op-assess for hemorrhage, infection, and thrombophlebitis; given hormone replacement therapy (HRT

The nurse instructs a new mother about how to care for her newborn's umbilical cord. The nurse determines teaching is effective if the client makes which statement? 1. I am going to bathe my baby in the new tub tomorrow 2. I will keep the cord covered with the diaper 3. I will clean the cord and skin around it with water 4. I will contact my physician if there is a white or yellow discharge from the cord. 5. I will pull the cord off when it becomes loose 6. I will apply petroleum jelly to the base of the cord

3. I will clean the cord and skin around it with water 4. I will contact my physician if there is a white or yellow discharge from the cord. ."Clean cord and surrounding area with water or solution preferred by the health care provider, report redness, drainage, or foul odor. Report redness, drainage, or foul odor.

A nurse teaches the client about birth control methods. How long should the nurse advise the client to leave a diaphragm in place after intercourse? 1. 6hrs 2. 8hrs 3. 10hrs 4. 12hrs

6hrs It is necessary for the diaphragm to remain in place for at least 6 hours to be effective in preventing pregnancy; can be inserted up to 6 hours prior to intercourse, but spermicide must be inserted into vagina with every intercourse.

An infant is born by vaginal delivery. At birth, the infant is crying and respiration and pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. The nurse should record the baby's one-minute and five-minute Apgar scores a which of the following? 1. 8 and 9 respectively 2. 8 and 10 respectively 3. 9 and 10 respectively 4. 9 and 7 respectively

9 and 10 respectively Need for resuscitation determined by Apgar score, performed at 1 and 5 minute: 0-2 points give for cardiac tone, respiration, muscle tone, reflexes, and color; 0-3 indicates severe distress, 4-6 indicates moderate difficulty, 7-10 indicates good adjustment to extra-uterine life; score at 1 min is 9 due to color.

The nurse notes that a 2 day old infant shows a tendency to bleed. The nurse understands this is MOST likely caused by which of the following? 1. Hemophilia 2. Absence of intestinal bacteria needed for the production of Vitamin K 3. Immature liver that is unable to synthesize clotting factors 4. Excessive breakdown of RBC's coupled with a delayed production of new ones.

Absence of intestinal bacteria needed for the production of Vitamin K newborns don't produce Vitamin K until the 8th day. Newborn given vitamin K at birth; bleeding due to newborn's inability to produce vitamin K the first three to four days; vitamin K produced in GI tract after microorganisms introduced; able to produced vitamin K by day eight.

A woman asks the nurse if she can safely drink wine while nursing her baby. Which of the following is the BEST response by the nurse? 1. The wine you drink will not be present in the breast milk 2. A moderate amount of wine will help you relax 3. Alcohol has a CNS depressant effect on the baby 4. Drink beer rather than wine while you are breastfeeding

Alcohol has a CNS depressant effect on the baby Acts as CNS depressant and is contraindicated.

By her fifth month of pregnancy, a 32 y/o multipara of average prenatal height and weight has gained 14lbs. Which of the following actions by the nurse is MOST important? 1. advise the client she has gained too much weight and her diet should be reevaluated 2. advise the client she has not gained enough weight and her diet should be reevaluated. 3. Inform the client her weight gain is appropriate and she should continue on her present diet. 4. Inform the client she may have difficulties later in pregnancy and more frequent visits to the physician are indicated.

Inform the client her weight gain is appropriate and she should continue on her present diet. . 14 lb wight gained during 5 months of pregnancy is appropriate.

The home care nurse makes a home visit to a client diagnosed with type 1 diabetes at 29 weeks gestation. The client states that she has been nauseated for 24 hours. It is MOST important for the nurse to ask which question? 1. Have you vomited 2. What was your last blood glucose reading 3. Have you taken your insulin today 4. When did you last eat

Have you taken your insulin today Important that client take prescribed insulin even though may not be eating regularly because insulin needs are increased during illness.

The nurse leads a prenatal class about breastfeeding. Which of the following statements, if made by the nurse, accurately describes the nutritional needs of a woman during lactation is compared tot he nutritional needs of pregnancy? 1. More calories, protein, and calcium are needed during lactation than are needed during pregnancy. 2. More calories but the same amount of protein, calcium, and fluids are needed. 3. Fewer calories and less protein are needed during lactation than are needed during pregnancy, but more calcium is needed. 4. Only more fat is needed during lactation than is needed during pregnancy.

More calories but the same amount of protein, calcium, and fluids are needed. More calories but the same amount of protein and calcium are needed during lactation.

A nurse accidentally bumps into a newborn's bassinet. The newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which of the following reflexes? 1. Tonic neck 2. Moro's 3. Babinski's 4. Rooting

Moro's Moro'sStartle reflex; disappears at 3-4 months

The nurse instructs a group of expectant mothers about the advantages of breastfeeding. The nurse should intervene if an expectant mother makes which of the following statements? 1. My baby will grow faster and sleep more with breast milk 2. My baby will receive protective immune factors from the breast milk 3. My baby will not need any other foods or milk until he is four months old 4. At first, I may feed my baby about 10x/day

My baby will grow faster and sleep more with breast milk Not a true statement; the advantages of breastfeeding include: the nutrients are easier for the infant to absorb, breast milk contains immune factors, it provides protections against allergies, and antibody responses to parenteral and oral vaccines are greater

A woman comes to the hospital in labor. Her membranes rupture at 4:10AM. Which of the following actions should the nurse take FIRST? 1. Identify the amniotic fluid by testing it or alkalinity 2. Contact physician and prepare for immediate delivery. 3. Note the time of rupture 4. Observe for a prolapsed cord or meconium stained fluid.

Observe for a prolapsed cord or meconium stained fluid. Signs of possible life-threatening complications to the fetus that may require emergency delivery.

The nurse cares for the client immediately after a normal vaginal delivery. Which action should the nurse take FIRST? 1. Observe the lochial flow 2. Palpate the fundus 3. Obtain a warming blanket 4. Obtain vital signs.

Observe the lochial flow Allows nurse to directly check for hemorrhage; inspection is the first step of physical assessment.

The nurse observes a staff member palpate uterine contractions. The nurse determines the staff member is using the correct technique if which of the following is observed? 1. place the palm of one hand on the fundus and move the palm of the other hand around the abdomen during contractions. 2. Place the heels of both hands on the lower abdomen and press lightly 3. Place one hand on the abdomen over the fundus and with the fingertips press gently 4. Place the palms of the hands on either side of the abdomen and press firmly.

Place one hand on the abdomen over the fundus and with the fingertips press gently Palpate with the fingertips; mild contractions (fundus easy to indent with fingertips; moderate contractions (feels like touching the tip of your nose); fundus is difficult to indent (feels like touching your chin); fundus board like and almost impossible to indent (feels like touching your forehead)

To assess an apical pulse on a 8lb, 4oz newborn infant, the nurse should take which of the following actions? 1. Place the diaphragm of the stethoscope between the nipple line and the sternal notch 2. Place the diaphragm of the stethoscope between the second and third intercostal spaces, the midaxillary line 3. Place the bell of the stethoscope between the fourth and fifth intercostal spaces, midclavicular line 4. Place the bell of the stethoscope between the second and third intercostal spaces, the midsternal line.

Place the bell of the stethoscope between the fourth and fifth intercostal spaces, midclavicular line Bell transmits low-pitched sounds like heart and vascular sounds; PMI usually found in the fourth to fifth intercoastal space medial to the left midclavicular line.

The parents of a preterm infant visit the infant in the newborn nursery. They see their infant resting comfortably in the isolette and express concern about disturbing the baby. Which of the following responses by the nurse is BEST? 1. Preterm infants have an immature immune system and handling them increases the risk of an infection 2. Preterm infants need to conserve their strength, so it is best if you do not pick the infant up 3. Preterm infants need to develop a sense of trust and security and holding the infant promotes this 4. Preterm infants can become irritable if handled while sleeping, so first wake the infant up.

Preterm infants need to develop a sense of trust and security and holding the infant promotes this Important to promote positive parent-child relationships; both parents and child have emotional needs that must be met; holding infant will promote trust.

The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in a preterm infant? 1. Red, wrinkled skin, lanugo, and hypotonic muscles 2. Vernix caseosa, silky hair, and faical edema 3. Absent nose bridge, depressed fontanels, and absent lanugo 4. Mottled skin, meconium stools, and hypertonic muscles

Red, wrinkled skin, lanugo, and hypotonic muscles vernix is the white substance covering baby's skin. Meconium stool is normal. herptonia is not seen with preterm infants. Red, wrinkled skin due to lack of subcutaneous fat that accumulates during third trimester; lanugo is downy fine hair found on shoulders, forehead, and cheeks and is more noticeable is preterm infants; floppy, poor head control, and limp extremities indicate hypotonia.

The nurse cares for clients in the prenatal clinic. The nurse identifies which of the following pregnant woman is MOST likely to have a problem with Rh incompatibility with her fetus? 1. RH-positive woman w/Rh-negative man, been pregnant twice, has received RhoGAM 2. Rh-negative woman w/Rh-positive man, who has Rh antibodies 3. Rh-positive woman w/Rh-positive man, previous aborted 12wk fetus, didn't receive RhoGAM 4. Rh-negative woman w/Rh-negative man, never received RHoGAM

Rh-negative woman w/Rh-positive man, who has Rh antibodies Since Rh-positive is dominant as long as there is one positive partner, infant will be Rh-positive; in this case, infant will be Rh-positive and mother Rh-negative; Rh antibodies that the mother has will break down infant's blood cells, creating incompatibility.

A woman complains to the nurse that during the client's menstrual period she gains weight and gets muscle cramps. The nurse should suggest which of the following measure to alleviate the client's symptoms? 1. Take OTC analgesics, restrict caffeine, exercise moderately 2. Avoid analgesics and exercise 3. Restrict fluid intake, exercise moderately, increase caffeine intake. 4. Restrict sodium intake, restrict exercise, sedatives

Take OTC analgesics, restrict caffeine, exercise moderately . The use of mild analgesics, restriction of caffeine, and moderate exercise have all been shown to be effective in relief of the wight gain, irritability, and muscle cramping of a menstrual period.

The nurse performs a home care visit on a mother who delivered a baby three days ago. The client expresses alarm when she hears that her baby has lost 8oz. Which of the following responses by the nurse is MOST appropriate? 1. Perhaps you don't have enough milk for the baby and need to supplement the diet with formula 2. That is normal weight loss. Sometimes babies lose as much as 10% of the birth weight. 3. Babies usually lose some weight, but that's more than usual. He may need an intravenous infusion. 4. Most babies immediately lose their intrauterine water deposits and 20% of their birth weight.

That is normal weight loss. Sometimes babies lose as much as 10% of the birth weight. Neonates can lose up to 10% of birth weight due to low levels of intake and excretion of fluids through lungs, bladder, and bowels; should regain weight by 10-14 days old.

The home care nurse visits a 17 y/o who delivered a full term infant 2 wks ago. Although the client appears mature, the nurse knows the client's age may interfere with positive mothering because of which of the following ? 1. The client is not in a stable relationship with the father 2. The client has yet to finish school 3. The client's parents want her to place the baby in foster care 4. The client is still experiencing the dependency of childhood

The client is still experiencing the dependency of childhood. The egocentric and concrete thinking of an adolescent may interfere with her ability to parent; adolescent may have unmet developmental needs and tasks that become an issue as she leaves the dependency of childhood and moves toward being and independent young adult.

The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's BP is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 gm/dL. Which of the following instructions by the nurse is MOST important? 1. The client should decrease caloric intake 2. The client should eliminate all salt from her diet 3. The client should ensure adequate protein 4. The client should increase her intake of iron

The client should ensure adequate protein Client has preclampsia; bedrest on left side. proteins restore osmotic pressure.

A woman arrives at the hospital in labor. The midwife states that the client is 4 cm dilated and 60% effaced. The nurse explains the the client this means which of the following? 1. The opening of the cervix is 4cm wide and the cervical canal is 60% shorter than normal 2. The cervix is 4cm short in dilation and 60% thinner than normal 3. The walls of the cervix ar 4cm thick and 60% shorter than normal 4. The cervix is 4cm long and 60% wider than normal

The opening of the cervix is 4cm wide and the cervical canal is 60% shorter than normal Dilation is stretching of the external os from an opening a few mm in size to an opening large enough to allow the passage of the infant (0-10 cm); effacement is the thinning and shortening or obliteration of the cervix; occurs in late pregnancy and/or labor.

The nurse observes the interactions of mother and infant born three hours ago. The mother had gestational diabetes and delivered by cesarean section at 37 weeks gestation. The infant's Apgar scores were 6 and 8, birth weight 10lbs, heart rate 122 bpm, and respirations 35/min. The mother tells the nurse, "I don't know why my physician was worried about my baby. She looks so big and healthy!". Which response by the nurse is BEST? 1. You need to ask your mother if you were also a large baby 2. They baby's large size is due to the amount of sugar the she received in utero 3. It is great that you are starting to rely on your maternal instinct already! 4. You must be relieved that the baby looks so healthly

They baby's large size is due to the amount of sugar the she received in utero Macrosomia of insulin-dependent diabetic mothers caused by poor maternal control; infant has round face, chubby body, and flushed complexion; infant at risk for hypoglycemia, hypocalcemia, and hyperbilirubinemia

On the evening before a modified radical mastectomy, a 29 y/o patient tells the nurse she is afraid that her husband will not find her sexually attractive if her breasts are removed. Which of the following responses by the nurse is BEST? 1. You shouldn't think about that tonight, you have plenty to worry about. 2. If your husband really lovers you, it won't bother him. 3. You're worried about how he'll react to the change in your body. 4. Reconstructive surgery can be done so that your breast will look the same.

You're worried about how he'll react to the change in your body. Reflects the patient's feelings and allows her to further express her feelings.

A 32 y/o woman is pregnant for the third time. She has one living child and had one abortion. Which description does the nurse record? 1. gravida III, para II 2. gravida II, para II 3. gravida III, para I 4. gravida II, para III

gravida III, para I Gravida = pregnancies Para = full term fetus Client is experiencing her third pregnancy (Gravida III), but in only one pregnancy did the fetus reach the age of viability (para I).

The nurse performs a home visit on a new mother and her two week old son. The mother is breastfeeding. She tells the nurse that the baby nurses 8-9 times a day, has regained all the lost birth weight, has 6-8 wet diapers and usually has one bowel movement at day. Which of the following responses by the nurse is BEST? 1. Your baby should be gaining more weight 2. I'm concerned about the number of daily bowel movements 3. Your baby is doing great 4. Decrease the number of times you feed the baby each day

Your baby is doing great The infant has regained the initial weight loss; well-hydrated infants should have 6-8 wet diapers per day; record results in the client record.

The nurse cares for a patient 24 hours after delivery, and the patient states that she has been voiding large amounts of urine. Which of the following responses by the nurse is BEST? 1. You probably have a UTI 2. Your body is getting rid of the increased fluid 3. You must be drinking copious amounts of fluid 4. Your blood sugar is probably elevated.

Your body is getting rid of the increased fluid Diaphoresis occurs for the first 2-3 days postpartum in order to decrease the retained fluids from the pregnancy

A nurse prepares a client for a gynecological examination. The nurse explains that the physician will perform a pelvis examination will obtain a Pap smear. The nurse explains the Pap smear is 1. taken from exudates of the vagina and cervix 2. a sample of tissue used to locate a lesion 3. an xray film taken from various angles 4. a specimen of cells used to identify abnormal cells

a specimen of cells used to identify abnormal cells A Pap smear is a routine procedure to identify infectious processes, the presence of abnormal cells, and hormonal changes

A nurse counsels a couple who have had difficulty conceiving a child. The nurse explains infertility is defined as which of the following? 1. inability to conceive after at least three months of unprotected intercourse 2. inability to conceive after at least six months of unprotected intercourse 3. inability to conceive after at least one year of unprotected intercourse 4. inability to conceive after at least two years of unprotected intercourse

inability to conceive after at least one year of unprotected intercourse The medical definition of infertility is inability to conceive after at least on year of unprotected intercourse.

A multipara woman in her fifth month of pregnancy complains to the nurse that her breasts are sensitive and sore. The nurse should make which of the following suggestions? 1. apply a warm compress and take aspirin 2. gently massage with lotion twice a day and wear loose fitting, comfortable clothing 3. apply cold compresses and wear a well fitting, supportive bra 4. take a diuretic once a day

apply cold compresses and wear a well fitting, supportive bra Breast soreness due to hormonal changes.

After a newborn circumcision, the nurse should take which of the following actions? 1. leave the area open to air 2. use disposable diapers to avoid irritation and facilitate healing 3. apply petroleum gauze and observe carefully for bleeding 4. administer prophylactic antibiotics

apply petroleum gauze and observe carefully for bleeding Observe for bleeding hourly during the first 12 hours; observe that infant is voiding; wash penis gently with water and apply petroleum around glans; yellow exudate should not be removed.

The nurse cares for the client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen mins later the nurse notes that the perineal pad is soaked and there is blood underneath the client's buttocks. Which action should the nurse perform first? 1. obtain the client's BP 2. notify the HCP 3. assess the fundus 4. administer O2 8-10L/min

assess the fundus Need to assess for uterine atony; tart IV with lactated Ringer's or normal saline may be taken as actions.

The nurse understands that the physician is most likely to prescribe which of the following drugs to a client diagnosed with gonorrhea? 1. penicillin vaginal suppositories 2. penicillin G benzthine intramuscularly in divided doses once a week 3. ceftriazone IM plus doxycycline for seven days, PO 4. ampicillin, PO

ceftriazone IM plus doxycycline for seven days, PO CDC recommended treatment for gonorrhea; instruct client how to prevent transmission of sexually transmitted infections.

The nurse instructs the woman about how to prevent conception using the basal body temp method. The nurse explains that during ovulation, the woman's basal body temp will change in which direction? 1. lowers significantly 2. rises significantly 3. is unchanged 4. rises slightly

rises slightly Just prior to ovulation, a woman's body temperature lowers about 1 degree at the time of ovulation, the body temperature increases about 1 to 2 degrees, this slight rise is important for clients who rely on methods of childbirth planning and depend on knowledge of the ovulatory cycle.

A 28 y/o woman delivers a baby boy. In order to monitor complications, the nurse should be MOST alert to which of the following findings? 1. complaints of pain 2. changes in blood pressure and pulse 3. ambivalent feelings about being a mother 4. the number of previous delivers

changes in blood pressure and pulse Elevated pulse and decreased blood pressure indicate hemorrhage.

The nurse cares for a patient 12 hours after delivery of a 3,200 g infant. The nurse notes that the fundus is approximately 1 cm above the umbilicus. It is most important for the nurse to take which of the following actions? 1. encourage the client to void 2. assess for the amount and character of the lochia 3. bring the infant to the mother for breastfeeding 4. chart the results in the patient's chart

chart the results in the patient's chart The fundus is about 1 cm above the umbilicus within 12 hours of the birth; after this time, should descend 1-2 cm each day.

The nurse instructs a pregnant woman with gestational diabetes about her diet. The nurse determines that teaching is effective is the client selects which of the following desserts? 1. apple pie 2. ice cream 3. cheese and fresh fruit 4. granola bar and milk

cheese and fresh fruit Contains appropriate nutrients for calories ingested

The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food? 1. chicken livers 2. pork 3. hamburger 4. tofu

chicken livers liver is an excellent source of iron. Chicken liversLiver is an excellent concentrated source of iron (7.2 mg per serving); recommended daily intake for women ages 19-50 is 18mg/day, men age 19 and up and postmenopausal women is 8 mg/day; other concentrated sources include cooked artichoke and some cereals (Grape-Nuts, Product 19, Total, Cream of Wheat, Oatmeal).

A woman is in active labor. As labor progresses, she becomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of these actions should the nurse take first? 1. contact the physician 2. coach the patient, in proper breathing and relaxation techniques 3. administer and analgesic 4. remove the fetal monitor to allow the client to move around

coach the patient, in proper breathing and relaxation techniques Assist client to cope with transition phase of labor: stay with client, provide constant reassurance, help client to reestablish breathing patterns, provide comfort.

The nurse cares for a client receiving magnesium sulfate IV, and the nurse notes that the client's deep tendon reflexes are decreased. Which action should the nurse take first? 1. document the results in the client's chart 2. place the call light within reach of the client 3. dim the lights prior to leaving the room 4. discontinue the IV infusion

discontinue the IV infusion Loss of reflexes or respiratory depression sign of magnesium toxicity, which may cause respiratory or cardiac arrest; discontinue infusion, contact physician; calcium gluconate at bedside

The nurse monitors a client at 30 weeks gestation, and the client states that she has periodic heartburn. It is MOST important for the nurse to make which of the following recommendations? 1. lie down after eating a meal 2. eat frequent small meals 3. take alka-seltzer as needed 4. sip iced tap water

eat frequent small meals Should advise against large meals and gas-producing or fatty foods; discouraged overeating.

The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take first? 1. instruct the patient to take a deep breath and bear down 2. apply pressure to the patient's fundus 3. coach the patient in relaxation techniques 4. encourage the patient to pant with pursed lips

encourage the patient to pant with pursed lips (pant to prevent pushing...) Encourage client to pant to prevent pushing, since she isn't fully dilated.

Meconium stained amniotic fluid should alert the nurse to the possibility of which? 1. fetal distress and perinatal asphyxia 2. fetal distress and hyperbilirubinemia 3. abruptio placenta and asphyxia 4. placenta previa and perinatal sepsis

fetal distress and perinatal asphyxia Possibly indicates hypoxia-induced peristalsis and sphincter relaxation.

The nurse palpates the fundus of a woman after the third stage of labor. The nurse should expect the fundus to be... 1. soft and discoid 2. firm and discoid 3. soft and globular 4. firm and globular

firm and globular Should be firm and globular and should rise.

A 25 y/o primigravida diagnosed with type 1 diabetes mellitus reviews insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following? 1. insulin requirements will increase during pregnancy and decrease after delivery 2. insulin requirements will decrease during pregnancy and increase after delivery 3. insulin requirements will increase during pregnancy and remain increased after delivery. 4. insulin requirements decrease during pregnancy and remain decreased after delivery.

insulin requirements will increase during pregnancy and decrease after delivery Due to hormonal interference in glucose metabolism, insulin requirements increase during pregnancy; however, immediately after delivery, the requirements usually decrease.

Which of the following measures is MOST effective in protecting the nursing staff from harmful exposure to radiation when caring for a patient with a radiation implant? 1. rotate the staff members assigned to the patient 2. wear a gown and mask when in contact with the patient 3. leave the patients room at least every 10 mins 4. place the patient in a room with private bathroom

rotate the staff members assigned to the patient It is important to remember to decrease the time and increase the distance when dealing with a patient with a radium implant; rotating the staff members will prevent excessive exposure to radiation

The nurse cares for a patient in labor. The nurse notes that patient appears more peaceful and there is an increase in bloody show. The nurse identifies the patient is in which stage of labor? 1. first 2. second 3. third 4. fourth stage

second stage A short period of peace and an increase in bloody show occur immediately before the baby is born at the beginning of the second stage of labor.

The nurse cares for a client immediately after delivery and administers oxytocin. The nurse knows that the purpose of the medication is 1. relieve discomfort and pain 2. anesthetize the area of the episiotomy 3. stimulate firm contraction of the uterus 4. prevent breast engorgement

stimulate firm contraction of the uterus Stimulates smooth muscles of uterus to contract; used to treat postpartum hemorrhage.

A couple comes to the fertility clinic after trying for several years to have children. The woman has a regular 28-day menstrual cycle. The nurse explains to her she is MOST likely to become pregnant 1. 10-14 days after the onset of her menstrual period 2. 16 days before the onset of her menstrual period 3. the last 8 days of her cycle 4. 18-20 days after the first day of her menstrual cycle

10-14 days after the onset of her menstrual period In a regular menstrual cycle of 28 days, the time of ovulation is usually around the 14th day; if the patient has intercourse 2 or 3 days before this time or 2 or 3 days after, it is possible that she will become pregnant, since the sperm live for about 48 hours.

A woman is in active labor when her membranes rupture. She expresses a concern to the nurse she is afraid of having a 'dry labor'. Which of the following responses by the nurse is MOST appropriate? 1. Amniotic fluid does not function as lubrication for the labor process 2. The sac actually impedes the progress of labor and if it had not ruptured, the doctor would have to do it artificially. 3. Labor is only slightly more difficult with early rupture of the amniotic sac. 4. Now that there is limited amniotic fluid, you may have to have a cesarean section.

Amniotic fluid does not function as lubrication for the labor process Helps maintain constant body temperature, provides oral fluids, cushions fetus.

The nurse teaches a class about gonorrhea. Which of the following statements, if made by a client, indicates that teaching is successful? 1. I've heard that having gonorrhea can make you unable to have children 2. They say this disease can affect your brain and make you go crazy 3. I've heard you can't get rid of gonorrhea. You keep getting it over and over again 4. My mother said that you need to have cesarean deliveries after this infection.

I've heard that having gonorrhea can make you unable to have children Gonorrhea causes pelvic inflammatory disease, which is one of the most common causes of sterility; gonorrhea is treated with antibiotics

The nurse counsels clients in the prenatal clinic. The nurse is MOST concerned if the client makes which statement? 1. I take my dog for a 30 min walk every other day 2. I plan to take an 8 hour car trip next week 3. I drink 3 liters of liquids every day 4. I clean the cat's litter box daily

I clean the cat's litter box daily Toxoplasmosis (protozoan infection) caused by eating infected under cooked meat or after handling infected kitty litter; infection can cross placenta and infect the fetus; pregnant women should not clean litter box, if she must, wear latex gloves and wash hands will afterward.

The nurse teaches prenatal classes in the antepartum clinic. Which of the following statements, if made by a client to the nurse, indicates that further teaching is necessary? 1. I may feel hot flashes and chills 2. I may experience constipation 3. I may have leg cramps during the night 4. I may feel irregular, painless contractions

I may feel hot flashes and chills Chills and fever indicate infection; report immediately to health care provider

The nurse instructs a prenatal client about the warning signs of pregnancy. The determines that teaching is successful if the client states the following? 1. I should contact the physician if I notice swelling in my face and fingers. 2. It's not unusual that I might have a little vaginal spotting 3. As long as my headaches go away after I take aspirin, I'm okay 4. I should report any uterine contractions that I may feel

I should contact the physician if I notice swelling in my face and fingers. Swelling of face or fingers may indicate hypertensive condition; other danger signs include gush of fluid or bleeding from vagina, regular uterine contractions, severe headaches, visual disturbances, abdominal pain, persistent vomiting, fever or chills.

The health care provider orders a colposcopy for the client. The nurse explains to the client that which is the purpose of this procedure? 1. Magnify the tissue for examination 2. Directly examine ovaries, fallopian tubes, uterus, and small intestine 3. View structures in the pelvis cavity 4. Visualize the bladder

Magnify the tissue for examination Examination of vagina and cervix using a colposcope; identified precancerous lesion of the cervix by magnifying the tissue for examination; instruct client that some bleeding may occur; can use vaginal tampons; client should report heavy bleeding.

The nurse instructs a group of expectant mothers about how to recognize the onset of labor. The nurse knows that further teaching is necessary if a client makes which statement? 1. My baby will move more when I go into labor 2. I may feel a gush of water at the beginning of labor 3. I may have blood tinged vaginal discharge 4. I will have regular uterine contractions that become stronger

My baby will move more when I go into labor Fetal movement remains unchanged during true labor.

The nurse assesses a client in the family planning clinic. Which of the following statements, if made b a client, suggests to the nurse that the client has been exposed to gonorrhea? 1. My boyfriend has a sore on his penis 2. I have a cheesy, white vaginal discharge 3. My boyfriend has a drip 4. I have a rash

My boyfriend has a drip Men complain of urethritis and epididymitis; women are frequently asymptomatic; diagnosed by culture of discharge from cervix or urethra; treatment is ceftriaxone and doxycycline.

The nurse prepares a client for a cesarean section. The client asks how the anesthesia is going to affect her baby. Which answer by the nurse is best? 1. The overall dosage of anesthesia is lower for a client undergoing cesarean section 2. The dosages of sedatives and hypnotics are lower for a client undergoing cesarean section 3. The amount of narcotic given is decreased in a client undergoing cesarean section 4. all medications are routinely withheld prior to the cesarean section.

The amount of narcotic given is decreased in a client undergoing cesarean section . Lower level of narcotic given to prevent respiratory depression in the infant and drowsiness at birth; reveals` of narcotics can be achieved by administering Narcan to the mother 15 min before delivery.

A young mother delivers a healthy 7lb 12oz boy. She confides to the nurse that she concerned about the two "soft spots" she found on her baby's head. The nurse's response should be based on which of the following? 1. both the baby's fontanels should close within the first month 2. both the baby's fontanels should close within six months 3. The baby's posterior fontanel should close after one year 4. The baby's anterior fontanel should close after about a year and a half.

The baby's anterior fontanel should close after about a year and a half.

A woman at 29 wks gestation comes to the ER complaining of vaginal bleeding. The nurse identifies which of the following patient statements as indicative of placenta previa? 1. The bleeding scares me, other than that I feel fine 2. I've been more nauseated during the past few weeks 3. The bleeding started after I carried in 4 bags of groceries 4. I've been having sever abdominal cramps

The bleeding scares me, other than that I feel fine ."Painless vaginal bleeding indicates placenta previa; placenta previa is a placenta that is abnormally implanted in the lower uterine segment; patient will be treated with bed rest, no vaginal exams, IVs to restore blood volume, monitor fetal well-being.

The nurse admits a patient to the postpartum unit two hours after a vaginal delivery. Three hours after admission the nurse ambulates the patient to the bathroom, and the patient states there is a sudden gush of bleeding from her vagina. The nurse understands that the increase in amount of bleeding is due to which of the following? 1. The lochia pooled in the patient's vagina when she was lying in bed 2. The patient has a tear in her cervix that needs to be repaired. 3. The patient's fundus is relaxed and requires massaging. 4. The patient's bladder is distended because she needs to void.

The lochia pooled in the patient's vagina when she was lying in bed Flow of lochia increases during ambulation and breastfeeding.

The 20 y/o woman arrives at the hospital in active labor. The client asks the nurse what is the purpose of fetal monitoring. Which response by the nurse is BEST? 1. The purpose of the fetal monitor is to evaluate the progress of labor 2. the purpose is to assess the strength and duration of contractions 3. The purpose is to determine if the fetus is receiving adequate amounts of oxygen 4. The purpose is to allow the health care provider to decide if an oxytocin drip should be started.

The purpose is to determine if the fetus is receiving adequate amounts of oxygen Monitor fetal heart rate patterns to assure that the fetus is receiving adequate amounts of oxygen during labor

The nurse prepares a client for an abdominal hysterectomy. The client asks why she has to have a Foley catheter. Which statement by the nurse is MOST appropriate? 1. This will help you since you will be temporarily incontinent 2. This will enable us to measure your output accurately 3. This will allow you to heal by keeping your bladder decompressed 4. This will allow your bladder to recover after the surgery.

This will allow you to heal by keeping your bladder decompressed An expanded bladder may interfere with wound healing by pressing on the wound: catheter is usually removed when client begins ambulating.

A client contacts the nurse and describes some soft and movable masses she felt in her breasts that become enlarged during menstruation. The nurse should be aware that the client is most likely describing which of the following? 1. cancer of the breast 2. fibroids of the breast 3. fibrocystic disease of the breast 4. hyperplasia of the breast

fibrocystic disease of the breast Fibrocystic disease of the breast involves benign cysts of the breast; present as soft, tender, freely moving cysts that become enlarged during menstruation.

The nurse care for a woman in labor. Which method should the nurse use to measure the frequency of a uterine contraction? 1. timing the contractions from end of one contraction to the end of the next contraction. 2. Timing the contraction from beginning of one to end of same contraction 3. Timing the contraction from peak of one to the beginning of next 4. Timing the contraction from beginning of one to beginning of next

Timing the contraction from beginning of one to beginning of next The standard measurement for contractions is from the beginning of one contraction to the beginning of the next contraction.

During auscultation of the fetal heart rate (FHR) during labor. The nurse assesses a rate of 59 beats/min. Which actions should the nurse take FIRST? 1. Turn the mother on her right side, open the IV line and call the HCP 2. Turn the mother on her left side, administer O2 NC and start and IV 3. Call the HCP 4. Place the mother in Trendelenburg, administer O2 and force fluids.

Turn the mother on her left side, administer O2 NC and start and IV Bradycardia indicates fetal distress; persistent bradycardia may indicate cord compression or separations of placenta

The nurse is caring for a patient in labor. The patient's labor progresses with regular contractions until her cervix is 9 cm dilated. The nurse identifies the patient is in which stage of labor? 1. first stage 2. second stage 3. third stage 4. fourth stage

first stage From the beginning of labor until the cervix is completely dilated is the first stage; divided into phase 1 (latent, 0-3 cm), phase 2 (active, 4-7 cm), phase 3 (transition, 8-10 cm).

The nurse explains to a client at 6 wks gestation which of the following periods of pregnancy is the most critical time for fetal development? 1. first two weeks 2. first three months 3. fourth through sixth month 4. the last month

first three months It is during the first trimester, or the first three months, that all the major systems of the fetus are developed; exposure of mother to noxious environmental agents can interfere with proper development of fetus.

The nurse cares for 4lb, 10oz infant delivered at 32 weeks gestation. The nurse notes the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The nurse recognized these findings are signs of which of the following? 1. Respiratory distress syndrome 2. cold stress 3. perinatal asphyxia 4. hypovolemia

cold stress Excessive loss of heat that results in increased respirations and non-shivering thermogeneis; metabolic acidosis occurs; place in heated environment.

During labor induction with oxytocin, the nurse should stop the infusion if which of the following occurs? 1. contractions are at 3 min intervals and last more than 60 secs 2. contractions are at 2 min intervals and last more than 90 secs 3. contractions are at 2.5 min intervals and last more than 90 secs 4. contractions are at 2 min intervals and last more than 60 secs

contractions are at 2 min intervals and last more than 90 secs It's extremely important for nurse to continually assess contractions for a patient receiving an oxytocin drip; if contractions occur too frequently (at intervals of less than 2 min) or last too long (more than 90s), they may endanger mother and fetus; nurse should stop infusion and notify physician.

When administering phototherapy to a newborn with jaundice, it is MOST important for the nurse to take which of the following actions? 1. expose only the infant's back to the light 2. remove the infant from the light for 15 mins each hour 3. cover the infant's eyes with protective pads during therapy 4. check the infant's temp every hour

cover the infant's eyes with protective pads during therapy Cover infant's eyes to protect from fluorescent lights; be sure nares are not covered with mask; close eyes prior to placing mask over the infant's eyes; remove during feeding so eyes can be checked and parents can have visual contact with infant

The nurse should place the HIGHTEST priority on monitoring a woman after a cesarean section for which of the following? 1. infection and pain 2. hemorrhage and shock 3. hemorrhage and pain management 4. dehydration and infection

hemorrhage and shock Client is not only an obstetrical client put also a post-op client; observe for patent airway, and observe incisional dressing from bleeding and amount of lochia.

The nurse cares for a woman in labor. The nurse is MOST concerned the fetus is experiencing distress if which is observed? 1. late decelerations 2. early decelerations 3. irregular heart rate 4. variable decelrations

late decelerations Fall in fetal heart rate after the peak of the contraction; indicates fetal hypoxia; position client on her left side, administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate.

The nurse cares for a patient after a breast biopsy. After the procedure, it is MOST important for the nurse to take which of the following actions? 1. apply ice to area 2. preposition the patient for comfort 3. carefully transport the specimen to the lab 4. observe for bleeding

observe for bleeding In the initial post-biopsy period, ligation of an artery or vein is the retest risk; nurse should observe for frank bleeding and pallor, cold, clammy skin, and an increased pulse and/or decreased blood pressure; always assess before implementing.

The nurse prepares a client for placement of internal radiation, The nurse understands the client will receive and indwelling foley catheter and a tap water enema for which of the following reasons? 1. prevent displacement of the implant 2. make the patient more comfortable during the treatment 3. maintain an uncontaminated work area 4. avoid excessive bladder and bowel irradiation

prevent displacement of the implant . If the bladder or the bowel is distended, the chance that the implant will be dislodged is increased; keeping the bladder from overfilling decreases the chance of implant displacement; a Foley catheter will remain in place and the patient will be kept on a low-residue diet.

The nurse instructs a patient who recently had a modified radical mastectomy. The nurse states that it is important that the patient exercise her arm postoperatively to 1. increase muscle strength and diameter 2. maintain body balance 3. limit full range of motion 4. prevent lymphedema

prevent lymphedema Postpoeratively, the nurse will encourage prescribed exercises and elevation of the extremity on the affected side to prevent lymphedema.

In the delivery room, the nurse places drops in a newborn's eyes. The nurse explains to the mother the drops 1. help the baby see well 2. remove blood and mucus from the baby's eyes 3. prevent neonatal conjunctivitis 4. protect against infections that could lead to blindness

protect against infections that could lead to blindness Legal requirements in the U.S.; instill erythromycin or tetracycline.

The nurse cares for a client diagnosed with cervical cancer. The nurse notes that the client appears to have a poor appetite. Which of the following interventions by the nurse is BEST? 1. provide high fat snacks 2. provide small, frequent feedings 3. provide additional fluid at meals 4. provide food when the client requests it.

provide small, frequent feedings Cardinal rule for increasing total caloric intake for client who has an inadequate intake or is anorexic is to provide small, frequent feedings; food may be tolerated better in the morning; if client complains of decreased taste, increased flavoring and seasoning in food.

The nurse knows that a preterm infant is at greatest risk for developing which disorder? 1. hypoglycemia 2. respiratory distress syndrome 3. hydrocephalus 4. scoliosis

respiratory distress syndrome Caused by under developed lungs and lack of surfactant

A fetal heart tracing shows and early deceleration pattern. The nurse is aware that this indicates which interpretation? 1. the FHR slows early in the contraction, which is a normal finding 2. the FHR slows early in the contraction, which is an abnormal finding 3. the FHR slows at the peak of the contraction, which is a normal finding. 4. the FHR slows at the peak of the contraction, which is an abnormal finding.

the FHR slows early in the contraction, which is a normal finding (deceleration occurs when the FHR falls below baseline for 15 s or more, followed by a return; early deceleration occurs before the peak of the contraction is is a reassuring fetal heart pattern)

A patient is admitted to the hospital and is scheduled to have a modified radical mastectomy. The patient asks the nurse about the surgical procedure. Which of the following explanations should the nurse give? 1. only the tissue is removed, leaving all the muscles and lymph nodes 2. the breast, axillary nodes and superior apical nodes are removed but he muscles are preserved. 3. the breast, axillary nodes, and the major and minor pectoral muscles are preserved. 4. The sternum will be split and lymph nodes will be dissected from the mediatinum

the breast, axillary nodes and superior apical nodes are removed but he muscles are preserved. In a modified radical mastectomy, the breast, axillary nodes, and superior apical nodes are removed, but the major and minor pectoral muscles are preserved.

The nurse supervises care for a client with a radioactive implant. The nurse should intervene if which of the following is observed? 1. The assistant gives the client a pan of water so the client can bathe herself 2. the assistant offers the client an analgesic for pain 3. the client's mother walks up to the client inside of her room 4. the staff wears a dosimeter film badge when interacting with the client

the client's mother walks up to the client inside of her room Client on bed rest while implant is in place; visitors should limit time spent in the client's room; do not stand close in line with radioactive source.

The nurse cares for 6lb, 7oz baby girl delivered two hours ago. The nurse knows which of the following occurrences initiates the changes that take place in the newborn circulatory system after birth? 1. the space constraints of the uterus are removed 2. the infant begins pulmonary ventilation 3. the infant is exposed to excessive sensory stimuli 4. the ambient temperature of the infant is reduced.

the infant begins pulmonary ventilation Lung inflation causes pressure in right atrium to decline, pressure is increased in the left atrium and the foramen ovale closes; ductus arteriosus occludes and becomes a ligament.

The school nurse attends a soccer game at the local high school. The nurse notes a pregnant woman has grabbed her throat, indicates that she is choking, and is unable to speak. Which of the following actions if taken by the nurse is BEST? 1. the nurse stand behind the woman and performs chest thrusts 2. the nurse inspects the client's mouth and throat for an obstruction 3. the nurse embraces the client from behind and performs abdominal thrusts 4. the nurse stays with the client calls for help

the nurse stand behind the woman and performs chest thrusts Perform chest thrusts rather than abdominal thrust due to pregnancy

A woman has a simple vulvectomy. Postop, the nurse instructs her to take a sitz bath and keep the area clean and dry. The nurse understands the reason for these measures is 1. to debride the area and prevent wound infection 2. to increase circulation to the area and promote wound healing 3. to prevent selling of the surround lymph nodes 4. to cleans the area and diminish the possibility of postop bleeding.

to increase circulation to the area and promote wound healing Both of these measures can be done to increase circulation to a vascular region such as the vulva, helping to promote wound healing.

The nurse instructs a client in the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which of the following food from a menu? 1. two eggs and 8oz milk 2. 2oz steak and 10oz beer 3. lettuce and tomato salad and 12oz OJ 4. bag of chips and 16oz soda

two eggs and 8oz milk Contains protein (three servings daily), calcium (three or more daily servings), and calories (no increase required during first trimester, +300 calories second and third

A woman comes to the clinic pregnant with her second child. She questions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is MOST important response by the nurse? 1. you can continue your activities but rest when you get tired. 2. you should take a brisk walk daily 3. you can exercise as much as you want but limit household activities 4. what is your usual type of exercise

what is your usual type of exercise Should exercise at least 3x per week; most important to determine regular exercise regimen before recommending an exercise program.

The nurse cares for newborn delivered by a mother addicted to narcotics. During which of the following times is the nurse MOST likely observe symptoms of narcotic withdrawal? 1. immediately at birth 2. within 12 hours after birth 3. within 24-72 hours after birth 4. after 2 weeks

within 24-72 hours after birth Infant will be jittery and hyperactive, high-pitched cry; diaphoresis, tachypnea.