Lippincots Q&A

71. Which of the following anticoagulants would the nurse expect to administer when caring for a primigravid client at 12 weeks' gestation who has class II cardiac disease due to mitral valve stenosis? ■ 1. Heparin. ■ 2. Warfarin (Coumadin). ■ 3. Enoxaparin (Lovenox). ■ 4. Ardeparin (Normiflo).

71. 1. Although there is no completely safe anticoagulant therapy during pregnancy, heparin is typically the drug of choice. Warfarin (Couma- din), a pregnancy category D drug, can cause fetal malformations. Enoxaparin (Lovenox) is not typi- cally prescribed because it can result in thrombocy- topenia. Ardeparin (Normifl o) also can cause fetal malformations. CN: Pharmacological and parenteral therapies; CL: Apply

29. A primagravid client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? ■ 1. "I need to call if I start to leak fl uid from my vagina." ■ 2. "If I start bleeding, I will need to call back." ■ 3. "If my baby does not move, I need to call my health care provider." ■ 4. "If I start running a fever, I should let the offi ce know."

29. 3. At 16 weeks' gestation, a primipara will not feel the baby moving. Quickening occurs between 18 and 20 weeks' gestation for a primi- para and between 16 and 18 weeks' gestation for a multipara. Leaking fluid from the vagina should not occur until labor begins and may indicate a rupture of the membranes. Bleeding and a fever are complications that warrant further evaluation and should be reported at any time during the pregnancy. CN: Health promotion and maintenance; CL: Evaluate

29. Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fonta- nel. The nurse documents its shape as which of the following? ■ 1. Oval. ■ 2. Square. ■ 3. Diamond shaped. ■ 4. Triangular.

29. 3. The anterior fontanel is normally diamond- shaped, approximately 2 to 3 cm wide and 3 to 4 cm long. This allows for brain growth during the early months of life. The posterior fontanel is small and triangular. CN: Health promotion and maintenance; CL: Analyze

30. A primiparous client has just delivered a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse inter- prets the father's actions as indicative of which of the following? ■ 1. Thanking Allah for giving him a male heir. ■ 2. Singing to his son from the Koran in praise of Allah. ■ 3. Expressing appreciation that his wife and son are healthy. ■ 4. Performing a ritual similar to baptism in other religions.

30. 2. The father is praying to Allah because of the Muslim belief that the fi rst sounds a child hears should be from the Koran in praise of and supplication to Allah. Although male children are revered in this culture, this practice is performed by Muslims whether the child is male or female. The father's actions are unrelated to his wife and son's being healthy. The nurse should allow the practice because doing so demonstrates cultural sensitivity and builds a trusting relationship with the fam- ily. The Muslim faith does not have a baptism rite whereby the child becomes a member of the faith. CN: Health promotion and maintenance; CL: Analyze

4. Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which of the following behaviors during this phase of labor? ■ 1. Excitement. ■ 2. Loss of control. ■ 3. Numbness of the legs. ■ 4. Feelings of relief.

4. 2. Assessment fi ndings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts. CN: Health promotion and maintenance; CL: Analyze

4. A neonate delivered at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate? ■ 1. Bathing the baby as soon after birth as possible. ■ 2. Use of eye patches with phototherapy. ■ 3. Use of humidity in the incubator. ■ 4. Use of a radiant warmer.

4. 3. Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease the insensible water loss. Bathing and the use of eye patches has no impact on insensible water loss. The use of a radiant warmer will increase the insensible water loss by drawing moisture out of the skin. CN: Reduction of risk potential; CL: Synthesize

119. The nurse in the newborn nursery has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which of the following in order of first to last? 1. Move quickly from room to room and assess all clients. 2. Check the room to which the new client will be admitted to be sure all supplies and equip- ment are available. 3. Log on to the clinical information system and determine if there are new orders. 4. Review notes from shift report and prioritize all clients; make rounds on the most critical fi rst.

4. Review notes from shift report and prioritize all clients; make rounds on the most critical first. 1. Move quickly from room to room and assess all clients. 3. Log on to the clinical information system and determine if there are new orders. 2. Check the room to which the new client will be admitted to be sure all supplies and equipment are available..Based on the report given by the preceding nurse, the nurse should plan to prioritize all clients and fi rst make rounds on the client needing the high- est level of nursing care. The nurse can then make rounds on all clients. The nurse can then check for new orders and, fi nally, inspect the room in which the next client will be admitted to be sure all of the equipment is available. CN: Management of care; CL: Synthesize

5. The nurse is explaining to a primagravida in labor that her baby is in a breech presentation, with the baby's presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how her baby is positioned? pic

5. 1. This fi gure shows the client's baby in a breech presentation with the baby facing the pelvis on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the pelvis. Figure 2 shows a vertex presentation with the baby in a left, occiput, anterior position (LOA). Figure 3 shows a vertex presentation, left, occipit, posterior (LOP). Figure 4 shows a face position with the baby in a left, mentum, transverse position (LMT). CN: Physiological adaptation; CL: Synthesize

40. Before placing the fetal monitoring device on a primigravid client's fundus, the nurse performs Leopold's maneuvers. When performing the third maneuver, the nurse explains that this maneuver is done for which of the following reasons? ■ 1. To determine whether the fetal presenting part is engaged. ■ 2. To locate the fetal cephalic prominence. ■ 3. To distinguish between a breech and a cephalic presentation. ■ 4. To locate the position of the fetal arms and legs.

40. 1. Leopold's maneuvers are performed to determine the presentation and position of the fetus. The third maneuver determines whether the fetal presenting part is engaged in the maternal pelvis. The fi rst maneuver distinguishes between a breech and a cephalic presentation through palpation of the top of the fundus. The second maneuver locates the fetal back, arms, and legs. The fetal heart rate moni- toring device should be placed near the fetal skull and back for optimal fetal heart rate monitoring. The fourth maneuver is done to locate the fetal cephalic prominence if the fetus is in a cephalic position. CN: Health promotion and maintenance; CL: Apply

40. A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepreg- nant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is: ■ 1. 4 weeks. ■ 2. 6 weeks. ■ 3. 8 weeks. ■ 4. 12 weeks.

40. 2. In most cases, unless complications develop or the client has gained excessive weight during the antepartal period, she can expect to return to her prepregnant weight by 6 weeks. Many clients lose 14 to 20 lb by 2 weeks postpartum, pri- marily because of the birth of the fetus, the placenta, and fl uid losses. Diet and exercise can help the cli- ent return to her prepregnant weight. CN: Health promotion and maintenance; CL: Apply

76. A preterm neonate is unable to breast- or bottle-feed. The physician writes an order to feed the neonate via nasogastric (NG) tube. When choos- ing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate's: ■ 1. Disease process. ■ 2. Gestational age. ■ 3. Length. ■ 4. Weight.

76. 4. The size of the nasogastric (NG) feed- ing tube is based on the neonate's weight. A larger feeding tube can be inserted into a heavier neonate. The disease process plays no role in the size of the feeding tube used. The neonate's weight and size can vary widely; thus, there is no standard tube size for any gestational age. Length will determine the depth at which the NG tube is placed in the stom- ach, not the size of the tube. CN: Basic care and comfort; CL: Synthesize

49. The nurse is completing discharge instruc- tions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions? ■ 1. "I will need to be checked out by the doctor in a week." ■ 2. "I need to wear a sports bra for a few days so I don't get milk." ■ 3. "I can get pregnant now if I don't use birth control." ■ 4. "I may feel sad for a few days but should be OK within a few days."

49. 1. The client will need a 4 to 6 week postpar- tum checkup to assure that she has returned to a pre-pregnancy state rather than 1 week postpartum. A sports bra will provide support to the breasts and decrease the chance that her milk will come in, or will provide support if she is breast-feeding. Some postpartum clients ovulate shortly after delivery and can become pregnant before having a fi rst period. Postpartum blues occurs within the fi rst 4 to 5 days postpartum and usually improves within 10 days postpartum, but the nurse should instruct the client to report any signs of feeling depressed to her health care provider. CN: Health promotion and maintenance; CL: Evaluate

8. Commercial formulas contain 20 calories per ounce. A 1-day-old infant's weight in the morning was 8 lb and he was fed 45 mL at 2 a.m., 5:30 a.m., 8 a.m., 11 a.m., 2 p.m., 4:30 p.m., 8 p.m., and 10:30 p.m. What is the total amount of calories the infant received today? ________________________ calories.

8. 240 calories 45 mL = 11⁄2 oz 11⁄2 oz × 8 feedings = 12 12 × 20 calories/oz = 240 calories CN: Physiological adaptation; CL: Apply

99. After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following? ■ 1. "I should clean her mouth with soapy water after feeding." ■ 2. "I should feed her in an upright position." ■ 3. "I need to remember to burp her often." ■ 4. "I may need to use a special nipple for feeding."

99. 1. After feeding, the mouth should be cleaned with sterile water, not soapy water, to reduce the risk for aspiration. The cleft lip should be cleaned with sterile water to prevent crusting before surgical repair. The neonate needs to be fed in an upright position to prevent aspiration. The neonate with a cleft lip and palate commonly swallows large amounts of air dur- ing feeding. Therefore, the neonate needs to be burped frequently to help eliminate the air and decrease the risk for regurgitation. The neonate with a cleft lip and palate should be fed with a special soft nipple that fi lls the cleft and facilitates sucking. CN: Reduction of risk potential; CL: Evaluate

The Nursing Care of the Childbearing Family

Antepartal Care

Test 3

The Birth Experience

1. A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses? ■ 1. "I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy." ■ 2. "My boyfriend can buy Plan B from the pharmacy if he is over 18 years old." ■ 3. "The birth control works by preventing ovulation or fertilization of the egg." ■ 4. "I may feel nauseated and have breast tenderness or a headache after using the contraceptive."

1. 1. Plan B is a series of contraceptive pills sim- ilar in composition to birth control pills that have been used for the past 30 years. Plan B is the brand name for levonorgestrel 0.75 mg. Pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later. Males can purchase this contraceptive as long as they are over 18 years of age. Common side effects include nausea, breast tenderness, vertigo, and stomach pain. CN: Physiological adaptation; CL: Evaluate

1. A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has occasional nasal fl aring. The newborn's temperature is 98; he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before delivery. Based on these data, the nurse should include which of the following in the management of the infant's care? ■ 1. Continue recording vital signs, voiding, stool- ing, and eating patterns every 4 hours for 24 hours, infant at bedside. ■ 2. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside. ■ 3. Transfer the newborn to the neonatal inten- sive care unit with diagnosis of possible sepsis, parents at bedside. ■ 4. Request CBC with differential from the health care provider, keep the newborn under the radiant warmer, and monitor vital signs every 4 hours, parents at bedside.

1. 2. The concern with this infant is sepsis based on prolonged rupture of membranes before delivery. Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal new- born, but a respiratory rate > 60, grunting, and occa- sional fl aring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with anti- biotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis but the changes in the WBC levels can identify an infant at risk. The use of the radiant warmer is not warranted for that length of time. CN: Reduction of risk potential; CL: Synthesize

1. The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client? ■ 1. Oxygen saturation monitoring every half hour. ■ 2. Supine positioning on back, if it is comfortable. ■ 3. Anesthesia/pain level assessment every 30 minutes. ■ 4. Vaginal bleeding, ROM assessment every shift.

1. 3. The nurse should monitor anesthesia/pain levels every 30 minutes during active labor to ascer- tain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client. When in active labor, oxygen saturation is not monitored unless there is a specifi c need, such as heart disease. The client should not be on her back but wedged to the right or left side to take the pressure off the vena cava. When lying on the back, the fetus compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30 minutes to 1 hour. CN: Reduction of risk potential; CL: Create

109. While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted? ■ 1. Bronze-colored skin. ■ 2. Maculopapular chest rash. ■ 3. Urine specifi c gravity of 1.018. ■ 4. Absent Moro reflex.

109. 4. An absent Moro refl ex, lethargy, opist- hotonos, and seizures are symptoms of bilirubin encephalopathy, which, although rare, can be life- threatening. Bronze discoloration of the skin and maculopapular chest rash are normal and are caused by the phototherapy. They will disappear once the phototherapy is discontinued. A urine specifi c grav- ity of 1.001 to 1.020 is normal in term neonates. CN: Reduction of risk potential; CL: Analyze

1. The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which of the following next to ensure the safest transition of the infant to the mother? ■ 1. Assess whether the mother is able to ambu- late to care for the infant. ■ 2. Ask the mother if there is anything else she needs for the care of her baby. ■ 3. Check the crib to determine if there are enough diapers and formula. ■ 4. Complete the hospital identification proce- dure with mother and infant.

1. 4. The hospital identification procedures for mothers and infants needs to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant, this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the pro- cess of transferring a baby to the mother, but iden- tifi cation verification is a safety measure that must occur first. CN: Safety and infection control; CL: Create

102. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a sei- zure. The nurse should do which in order of priority from first to last? 1. Call for immediate assistance. 2. Turn the client to her side. 3. Note the time when the seizure began. 4. Maintain airway.

1. Call for immediate assistance. 3. Maintain airway. 2. Turn the client to her side. 4. Note the length of time of seizure. If a client begins to have a seizure, the fi rst action by the nurse is to remain with the client and call for immediate assistance. Next, the nurse should turn the client to her side and then maintain the airway by keeping the neck hyperextended. Noting the length of the seizure and the limb involvement are observations that are ongoing. CN: Management of care; CL: Synthesize

10. A 22-year-old nulligravid client tells the nurse that she and her husband have been consider- ing using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning? ■ 1. Using a spermicide with the condom offers added protection against pregnancy. ■ 2. Natural skin condoms protect against sexu- ally transmitted diseases. ■ 3. The typical failure rate for couples using con- doms is about 25%. ■ 4. Condom users commonly report penile gland sensitivity.

10. 1. The typical failure rate of a condom is approximately 12% to 14%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy. Natural skin condoms do not offer the same protec- tion against sexually transmitted diseases caused by viruses as latex condoms do. Unlike latex condoms, natural skin (membrane) condoms do not prevent the passage of viruses. Most condom users report decreased penile gland sensitivity. However, some users do report an increased sensitivity or aller- gic reaction (such as a rash) to latex, necessitating the use of another method of family planning or a switch to a natural skin condom.

10. After the nurse explains to the mother of a male neonate scheduled to receive an injection of vitamin K soon after birth about the rationale for the medication, which of the following statements by the mother indicates successful teaching? ■ 1. "My baby doesn't have the normal bacteria in his intestines to produce this vitamin." ■ 2. "My baby is at a high risk for a problem involving his blood's ability to clot." ■ 3. "The red blood cells my baby formed during pregnancy are destroying the vitamin K." ■ 4. "My baby's liver is not able to produce enough of this vitamin so soon after birth."

10. 1. To begin vitamin K synthesis, which occurs in the intestines, food and normal intestinal fl ora are needed. However, at birth, the neonate's intestines are sterile. Therefore, vitamin K is admin- istered via injection to prevent a vitamin K defi - ciency that may result in a bleeding tendency. When administered, vitamin K promotes formation in the liver of clotting factors II, VII, IX, and X. Neonates are not normally susceptible to clotting disorders, unless they are diagnosed with hemophilia or dem- onstrate a defi ciency of or a problem with clotting factors. Hemolysis of fetal red blood cells does not destroy vitamin K. Hemolysis may be caused by Rh or ABO incompatibility, which leads to anemia and necessitates an exchange transfusion. Vitamin K synthesis occurs in the intestines, not the liver. CN: Pharmacological and parenteral therapies; CL: Evaluate

10. A primigravida is admitted to the labor area with ruptured membranes and contractions occur- ring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is: ■ 1. The cervix will begin to dilate 2 centimeters per hour. ■ 2. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions. ■ 3. The cervix will change from fi rm to soft, efface to 40% to 50%, and move from a poste- rior to anterior position. ■ 4. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.

10. 2. The goal of oxytocin (Pitocin) administra- tion in labor augmentation is to establish an ade- quate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contrac- tions occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a pal- pable resting tone between contractions. Other con- traction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 centime- ters per hour is too rapid for the induction/augmen- tation process. CN: Pharmacological and parenteral therapies; CL: Evaluate

10. After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effec- tive when the client says that she will count the number of times the baby moves during which of the following time spans? ■ 1. 30-minute period three times a day. ■ 2. 45-minute period after lunch each day. ■ 3. 1-hour period each day. ■ 4. 12-hour period each week.

10. 3. Numerous methods have been proposed to record the maternal perceptions of fetal movement or "kick counts." A commonly used method is the Cardiff count-to-10 method. The client begins count- ing fetal movements at a specifi ed time (e.g., 8:00 a.m.) and notes the time when the 10th movement is felt. If the client does not feel at least 6 movements in a 1-hour period, she should notify the health care provider. The fetus typically moves an average of 1 to 2 times every 10 minutes or 10 to 12 times per hour. A 30- or 45-minute period is not enough time to evaluate fetal movement accurately. The client should monitor fetal movements more frequently than 1 time per week. One hour of monitoring each day is adequate. CN: Reduction of risk potential; CL: Evaluate

10. The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The cli- ent is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client? ■ 1. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n. ■ 2. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n. ■ 3. Colace 100 mg P.O. b.i.d. ■ 4. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.

10. 4. Acetaminophen and hydrocodone (Vico- din) would be the drug of choice for this situation because the pain level is so high. Aspirin is not usually used because of the bleeding risk associated with its use. Although ibuprofen would typically be a good choice because it inhibits the prostaglan- din synthesis associated with a multiparous client breast-feeding, the pain level is too high for this drug to have an acceptable effect. Docusate (Colace) is used as a stool softener postpartum but does not provide pain relief. CN: Pharmacological and parenteral therapies; CL: Synthesize

100. While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the cli- ent's physician immediately if the client exhibited which of the following? ■ 1. Pain in her calf. ■ 2. Dyspnea. ■ 3. Hypertension. ■ 4. Bradycardia.

100. 2. A major complication of deep vein throm- bosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immedi- ate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, dia- phoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hyperten- sion, would suggest a possible pulmonary embo- lism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy. Bradycar- dia for the fi rst 7 days in the postpartum period is normal. CN: Reduction of risk potential; CL: Synthesize

100. A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant? ■ 1. Use an appropriate nipple and bottle set. ■ 2. Encourage the mother to breast-feed. ■ 3. Assess daily weights and wet diapers to monitor intake. ■ 4. Allow unlimited length of time for each feed- ing.

100. 2. Breast-feeding is the method of choice for all neonates. Infant feeding is more diffi cult for infants with cleft palates because of the inability to create a seal around the nipple. Maternal nipples most readily conform to the palate and create an adequate seal. Secondarily utilizing a nipple espe- cially made for the particular cleft facilitates the seal and encourages an easier suck and swallow. Assessing the infant's weight and wet diapers on a daily basis monitors the hydration and nutritional status. An unlimited length of time for each feeding can cause fatigue and poor weight gain. CN: Health promotion and maintenance; CL: Apply

101. A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which of the following? ■ 1. Epistaxis. ■ 2. Bleeding gums. ■ 3. Slow pulse. ■ 4. Petechiae.

101. 3. A slow pulse (bradycardia) is normal for the fi rst 7 days postpartum as the body begins to adjust to the decrease in blood volume and return to the prepregnant state. Adverse effects of hepa- rin therapy suggesting prolonged bleeding include hematuria, epistaxis, increased lochial fl ow, and bleeding gums. Typically, tachycardia, not bradycar- dia, would be associated with hemorrhage. Pete- chiae indicate bleeding under the skin or in subcu- taneous tissue. CN: Reduction of risk potential; CL: Evaluate

100. The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a prior- ity in this neonate? ■ 1. Anemia. ■ 2. Hypoglycemia. ■ 3. Delayed meconium. ■ 4. Elevated bilirubin.

100. 2. Postmature neonates commonly have diffi culty maintaining adequate glucose reserves and usually develop hypoglycemia soon after birth. Other common problems include meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity, and cold stress. These complications result primarily from a combination of advanced gestational age, placental insuffi ciency, and continued exposure to amniotic fl uid. Delayed meconium is not associated with post-term gesta- tion. Hyperbilirubinemia occurs in term neonates as well as post-term neonates, but unless there is an Rh incompatibility it does not develop until after the fi rst 24 hours of life. CN: Reduction of risk potential; CL: Analyze

100. The nurse is planning care for a group of preg- nant clients. Which of the following clients should be referred to a health care provider immediately? ■ 1. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine. ■ 2. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly. ■ 3. A woman at 32 weeks' gestation and is preec- lamptic with +3 proteinuria. ■ 4. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.

100. 3. The nurse should refer the client who is preeclamptic client with 3+ proteinuria to a health care provider. The 3+ urine is signifi cant, indicating there is much protein circulating. The woman who is 37 weeks' gestation with insulin-dependent diabetes who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tab- lets until the client can obtain an appointment with the care provider. The client at 10 weeks' gestation with nausea and vomiting and + 1 ketones should also be seen by a health care provider, but at this point this client is uncomfortable but her life is not in danger. The 15-week primigravid client will not be feeling her baby move this soon in the pregnancy and this would not be considered a problem that requires immediate referral to a health care provider. CN: Management of care; CL: Evaluate

100. A woman who has had asthma since she was a child and it is under control when the client takes her medication correctly and consistently is now pregnant for the fi rst time. Which of the following client statements concerning asthma during preg- nancy indicates the need for further instruction? ■ 1. "I need to continue taking my asthma medica- tion as prescribed." ■ 2. "It is my goal to prevent or limit asthma attacks." ■ 3. "During an asthma attack, oxygen needs con- tinue to be high for mother and fetus." ■ 4. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

100. 4. Asthma medications and bronchodila- tors should be continued during pregnancy as prescribed before the pregnancy began. The medi- cations do not cause harm to the mother or fetus. Regular use of asthma medication will usually pre- vent asthma attacks. Prevention and limitation of an asthma attack is the goal of care for a client who is or is not pregnant and is the appropriate care strategy. During an asthma attack, oxygen needs continue as with any pregnant client but the air- ways are edematous, decreasing perfusion. Asthma exacerbations during pregnancy may occur as a result of infrequent use of medication rather than as a result of the pregnancy. CN: Pharmacological and parenteral therapies; CL: Evaluate

107. While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which of the following stages of grief? ■ 1. Denial. ■ 2. Shock. ■ 3. Bargaining. ■ 4. Anger.

107. 2. The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bar- gaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition. CN: Psychosocial adaptation; CL: Analyze

101. A client with pregnancy-induced hyper- tension is to receive magnesium sulfate to run at 3 grams per hour with normal saline to maintain the total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncom- ing nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last. 1. Notify the physician of the incident. 2. Assess the client's current status 3. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour. 4. Initiate an incident report.

101. 3. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour. 2. Assess the client's current status 1. Notify the physician of the incident. 4. Initiate an incident report. The nurse should fi rst change the I.V. magnesium sul- fate and normal saline infusion rates, and then assess the current status of the client. The nurse should then notify the physician to explain the error and, report the action taken. A medication error has occurred and the nurse will need to initiate an incident report. CN: Management of care; CL: Synthesize

101. A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client? ■ 1. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. ■ 2. Refer the client to her health care provider for evaluation and treatment of the pain. ■ 3. Discuss nutritional strategies to decrease the possibility of heartburn. ■ 4. Support the client's use of acetaminophen (Tylenol) to relieve pain.

101. 2. The nurse seeing this client should refer her to a health care provider for further evalua- tion of the pain. This referral would allow a more defi nitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symp- toms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the infl uence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major em- phasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heart- burn are appropriate during pregnancy, but not in this situation. Tylenol is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems. CN: Management of care; CL: Synthesize

101. A multigravid client in active labor at term is diagnosed with polyhydramnios. The physician has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydram- nios is associated with which of the following in the fetus or neonate? ■ 1. Renal dysfunction. ■ 2. Intrauterine growth retardation. ■ 3. Pulmonary hypoplasia. ■ 4. Gastrointestinal disorders.

101. 4. Polyhydramnios is an abnormally large amount of amniotic fl uid in the uterus. The client has understood the instructions when the client states that polyhydramnios is associated with gastro- intestinal disorders (e.g., tracheoesophageal fi stula). Polyhydramnios is also associated with maternal illnesses such as diabetes and anemia. Other fetal/ neonatal disorders associated with this condition include congenital anomalies of the central nervous system (e.g., anencephaly), upper gastrointestinal obstruction, and macrosomia. Polyhydramnios can lead to preterm labor, premature rupture of the membranes, and cord prolapse. Renal dysfunction and intrauterine growth retardation are associated with oligohydramnios, not polyhydramnios. Pulmo- nary hypoplasia (poorly developed lungs) is associ- ated with prolonged oligohydramnios. CN: Reduction of risk potential; CL: Evaluate

101. A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instruc- tions should the nurse expect to include when developing the teaching plan for the mother about FAS? ■ 1. Withdrawal symptoms usually do not occur until 7 days postpartum. ■ 2. Large-for-gestational-age size is common with this condition. ■ 3. Facial deformities associated with FAS can be corrected by plastic surgery. ■ 4. Symptoms of withdrawal include tremors, sleeplessness, and seizures.

101. 4. The long-term prognosis for neonates with FAS is poor. Symptoms of withdrawal include tremors, sleeplessness, seizures, abdominal disten- tion, hyperactivity, and inconsolable crying. Symp- toms of withdrawal commonly occur within 6 to 12 hours or, at the latest, within the fi rst 3 days of life. The neonate with FAS is usually growth defi cient at birth. Most neonates with FAS are mildly to severely mentally retarded. The facial deformities, such as short palpebral fi ssures, epicanthal folds, broad nasal bridge, fl attened midfacies, and short, upturned nose are not easily corrected with plastic surgery. CN: Reduction of risk potential; CL: Create

102. A primigravid client at 39 weeks' gesta- tion is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at 21 sta- tion. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experienc- ing which of the following? ■ 1. Cephalopelvic disproportion. ■ 2. Prolonged latent phase. ■ 3. Prolonged transitional phase. ■ 4. Hypotonic contraction pattern.

102. 1. If a client has been in active labor and there is no change in cervical dilation after 2 hours, the nurse should suspect cephalopelvic disproportion. This may be caused by an inadequate pelvis size of the mother or by a large-for-gestational-age fetus. The physician should be notifi ed about the client's lack of progress. If the fetus cannot descend, a cesar- ean delivery is warranted. The client is not experi- encing a prolonged latent phase (0 to 3 cm dilation), because her cervix is dilated to 6 cm. She has not reached the transitional phase, characterized by a cervical dilation of 8 to 10 cm. With a hypotonic labor pattern, contractions are painful but far apart and not very intense. This client's contractions are of moderate intensity. CN: Reduction of risk potential; CL: Analyze

102. A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifi es her as being at the highest risk for developing which problem? ■ 1. Abruptio placentae. ■ 2. Placenta previa. ■ 3. Disseminated intravascular coagulation. ■ 4. Threatened abortion.

102. 3. A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," fi rm consistency of the abdomen (abrup- tion) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no complaints of cramping or vaginal bleeding. CN: Management of care; CL: Analyze

102. Which of the following characteristics should the nurse teach the mother about her neonate diag- nosed with fetal alcohol syndrome (FAS)? ■ 1. Neonates are commonly listless and lethargic. ■ 2. The IQ scores are usually average. ■ 3. Hyperactivity and speech disorders are com- mon. ■ 4. The mortality rate is 70% unless treated.

102. 3. Central nervous system disorders are com- mon in neonates with FAS. Speech and language disorders and hyperactivity are common manifesta- tions of central nervous system dysfunction. Mild to severe mental retardation and feeding problems also are common. Delayed growth and develop- ment is expected. These neonates feed poorly and commonly have persistent vomiting until age 6 to 7 months. These neonates do not have a 70% mor- tality rate, and there is no treatment for FAS. CN: Reduction of risk potential; CL: Apply

102. After being treated with heparin therapy for thrombophlebitis, a multiparous client who deliv- ered 4 days ago is to be discharged on oral war- farin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching? ■ 1. "I can take two aspirin if I get uterine cramps." ■ 2. "Protamine sulfate should be available if I need it." ■ 3. "I should use a soft toothbrush to brush my teeth." ■ 4. "I can drink an occasional glass of wine if I desire."

102. 3. Successful teaching is demonstrated when the client says, "I should use a soft toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-infl ammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the anti- dote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabo- lism of oral anticoagulants and should be avoided. CN: Pharmacological and parenteral therapies; CL: Evaluate

103. A 40-year-old client at 8 weeks' gestation has a 3-year-old child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling as genetic screening methods for the expected baby. The nurse is confi dent that the teaching has been understood when the client states which of the following? ■ 1. "Each test identifi es a different part of the infant's genetic makeup." ■ 2. "Chorionic villus sampling can be performed earlier in pregnancy." ■ 3. "The test results take the same length of time to be completed." ■ 4. "Amniocentesis is a more dangerous proce- dure for the fetus."

103. 2. Chorionic villus sampling (CVS) can be performed from approximately 8 to 12 weeks' gesta- tion, while amniocentesis cannot be performed until between 11 weeks' gestation and the end of the pregnancy. Eleven weeks' gestation is the earliest possible time within the pregnancy to obtain a suf- fi cient amount of amniotic fl uid to sample. Because CVS take a piece of membrane surrounding the infant, this procedure can be completed earlier in the pregnancy. Amniocentesis and chorionic villus sampling identify the genetic makeup of the fetus in its entirety, rather than a portion of it. Laboratory analysis of chorionic villus sampling takes less time to complete. Both procedures place the fetus at risk and postprocedure teaching asks the client to report the same complicating events (bleeding, cramping, fever, and fl uid leakage from the vagina). CN: Management of care; CL: Evaluate

103. The physician who elects to perform a cesar- ean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I'll sign it for her. She's too upset by what is happening to make this decision." The nurse should: ■ 1. Ask the client if this is acceptable to her. ■ 2. Have the client and her husband both sign the consent form. ■ 3. Ask the client to sign the consent form. ■ 4. Ask the doctor to witness the consent form.

103. 3. Preparation for cesarean delivery is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain desig- nated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both. CN: Management of care; CL: Synthesize

103. A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruc- tion when she says which of the following? ■ 1. "The way my baby's face looks now will stay that way." ■ 2. "My baby may be irritable as a newborn." ■ 3. "I may need some help coping with my new- born." ■ 4. "My baby will be fi ne soon after we are home."

103. 4. Changes seen in the facial features of newborns with fetal alcohol syndrome remain that way. These include epicanthal folds, whorls, irregu- lar hair, cleft lip or palate, small teeth, and lack of fi ltrum. Newborns with fetal alcohol syndrome are usually diffi cult to calm and frequently cry for long periods of time. Parents do need assistance with caring for themselves and their infants, particularly with continued alcohol use. A supportive family or support systems are essential. The problems seen with this newborn do not go away and remain with the infant throughout life and are compounded when the child begins to develop mentally. CN: Health promotion and maintenance; CL: Evaluate

103. A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory track infection following delivery. The nurse determines the client understands principles of infection control to follow when the client says: ■ 1. "I must use barrier isolation." ■ 2. "I must wear a gown and gloves." ■ 3. "I must use individual client care equip- ment." ■ 4. "I must practice frequent hand washing."

103. 4. Frequent hand washing is the most impor- tant aspect of infection control.. The nurse can emphasize, monitor, and ensure this strategy for all who come in contact with this client. The use of gowns and gloves are appropriate when there is blood and stool. Barrier isolation and individual cli- ent care equipment are not needed in this situation. CN: Reduction of risk potential; CL: Evaluate

104. A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibi- otic therapy with ampicillin sodium (Polycillin). Before administering this drug, the nurse must do which of the following? ■ 1. Ask the client if she has any drug allergies. ■ 2. Assess the client's pulse rate. ■ 3. Place the client in a side-lying position. ■ 4. Check the client's perineal pad.

104. 1. Before administering ampicillin sodium (Polycillin) intravenously, the nurse must ask the client if she has any drug allergies, especially to penicillin. Antibiotic therapy can cause adverse effects, such as rash or even anaphylaxis. If the cli- ent is allergic to penicillin, the physician should be notifi ed and ampicillin should not be given. Check- ing the client's pulse rate or placing her in a side- lying position and are not necessary. Assessing the amount of lochia by checking the perineal pad is important for all postpartum clients but is not neces- sary before antibiotic therapy. CN: Pharmacological and parenteral therapies; CL: Apply

104. After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which of the following? ■ 1. Denial of the pregnancy. ■ 2. Low-birth-weight infant. ■ 3. Cephalopelvic disproportion. ■ 4. Congenital anomalies.

104. 4. Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents are at greater risk for denial of the pregnancy, lack of pre- natal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional defi cits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies. CN: Health promotion and maintenance; CL: Evaluate

104. A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean deliv- ery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intrave- nously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which of the following? ■ 1. Maternal fatigue. ■ 2. Fetal malposition. ■ 3. Small-for-gestational-age fetus. ■ 4. Effects of analgesic medication.

104. 4. Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anes- thesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and arrhyth- mias. Maternal fatigue, fetal malposition, and small- for-gestational-age fetus are not commonly associ- ated with decreased variability. CN: Health promotion and maintenance; CL: Apply

104. When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse expect to do fi rst? ■ 1. Weigh the neonate. ■ 2. Insert an orogastric tube. ■ 3. Prepare for immediate blood transfusion. ■ 4. Cover the abdomen with a moistened sterile gauze.

104. 4. Gastroschisis is a rare anomaly character- ized by the evisceration of abdominal contents through a full-thickness defect in the abdominal wall. The nurse should fi rst protect the abdominal contents with sterile gauze moistened with sterile saline. Immediate surgery is required. Weighing the neonate is not a priority at this time, but it may need to be done before surgery to determine the appropriate amount of anesthesia. An orogastric tube is not necessary because the infant will not be fed before surgery. An immediate blood transfusion is not needed at this time. CN: Reduction of risk potential; CL: Synthesize

105. The father of a neonate diagnosed with gastro- schisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teach- ing plan about feeding the neonate? ■ 1. The neonate will remain on nothing-by- mouth (NPO) status until after surgery. ■ 2. An iron-fortifi ed formula will be given before surgery. ■ 3. The neonate will need total parenteral nutri- tion for nourishment. ■ 4. The mother may breast-feed the neonate before surgery.

105. 1. The parents need to know that the neonate will be kept on NPO status and will receive intrave- nous therapy before surgery. After surgery, feeding will depend on the neonate's condition. Total paren- teral nutrition may be ordered after surgery, but not before. Breast-feeding may be started after surgery if the neonate's condition is stable. The mother can pump the breasts until that time. CN: Reduction of risk potential; CL: Apply

105. Which of the following would be most impor- tant for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy? ■ 1. Ambulate to the bathroom frequently. ■ 2. Discontinue breast-feeding temporarily. ■ 3. Maintain bed rest in Fowler's position. ■ 4. Restrict visitors to prevent contamination.

105. 3. The nurse should encourage the client to maintain Fowler's position, which promotes comfort and facilitates drainage. Endometritis can make the client feel extremely uncomfortable and fatigued, so ambulation during intravenous therapy is not as important at this time. The client does not need to discontinue breast-feeding, although she may become quite fatigued and need assistance in caring for the neonate. Typically, breast-feeding would be discontinued only if the mother lacks the necessary energy. The institution's policy regarding visitors is to be followed. However, visitors do not need to be restricted to prevent contamination because the client is not considered to be contagious. The nurse should maintain the client's need for privacy and rest and should respect the client's wishes related to visitors. CN: Reduction of risk potential; CL: Synthesize

105. The nurse is caring for a primipara in active labor when the fetus develops severe bradycardia with late decelerations, and an emergency cesarean delivery is performed with the client under general anesthesia. After the delivery, the client tells the nurse, "I feel terrible. This is exactly what I didn't want to happen!" Which of the following is a prior- ity nursing diagnosis for this client? ■ 1. Interrupted family processes related to cesar- ean delivery. ■ 2. Anxiety related to incisional scar and neona- tal outcome. ■ 3. Pain related to surgical incision and uterine cramping. ■ 4. Situational low self-esteem related to inability to deliver vaginally.

105. 4. It is not unusual for clients who undergo an emergency cesarean delivery to express thoughts of failure. Pain, hemorrhage, and anxiety may all occur, but the priority diagnosis at this time is Situ- ational low self-esteem. In this situation, the nurse should be supportive and should allow the client to verbalize any feelings of failure, guilt, or anger. Nursing care should include reviewing the events that occurred and clearing up any questions or mis- conceptions. CN: Psychosocial adaptation; CL: Analyze

105. A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which of the following feelings? ■ 1. Ambivalence. ■ 2. Anxiety. ■ 3. Fear. ■ 4. Guilt.

105. 4. With a spontaneous abortion, many clients and their partners feel an acute sense of loss. Their grieving commonly includes feelings of guilt, which may be expressed as wondering whether the woman could have done something to prevent the loss. Anger, sadness, and disappointment are also com- mon emotions after a pregnancy loss. Ambivalence, anxiety, and fear are not common emotions after a spontaneous abortion. CN: Psychosocial adaptation; CL: Analysis

106. The nurse is developing a plan of care for a neonate who is to undergo gastroschisis surgery. What should be included? Select all that apply. ■ 1. Prevention of hypothermia. ■ 2. Maintenance of fl uid and electrolyte balance. ■ 3. Provision of time for parental bonding. ■ 4. Prevention of infection. ■ 5. Providing developmental care.

106. 1, 2, 4. The major goals for the neonate include preventing hypothermia, maintaining fl uid and electrolyte balance, and preventing infection. The neonate needs immediate surgery, so bonding is not a priority at this time. Developmental care is important and should be addressed after the closure of the abdominal wall defect. CN: Reduction of risk potential; CL: Create

106. When providing care to the client who has undergone a dilatation and curettage (D&C) after a spontaneous abortion, the nurse administers hydroxyzine (Vistaril) as ordered. Which of the fol- lowing is an expected outcome? ■ 1. Absence of nausea. ■ 2. Minimized pain. ■ 3. Decreased uterine cramping. ■ 4. Improved uterine contractility.

106. 1. Hydroxyzine (Vistaril) has a tranquilizing effect and also decreases nausea and vomiting. It does not decrease fl uid retention, reduce pain, de- crease uterine cramping, or promote uterine contrac- tility. One of the adverse effects of the medication is sleepiness. Ibuprofen may decrease pain from uterine cramping. Oxytocin may be used to increase uterine contractility. CN: Pharmacological and parenteral therapies; CL: Evaluate

90. During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which of the following exercises suggested by the nurse would be most helpful? ■ 1. Pelvic rocking. ■ 2. Deep breathing. ■ 3. Tailor sitting. ■ 4. Squatting.

90. 1. Pelvic rocking helps to relieve backache during pregnancy and early labor by making the spine more fl exible. Deep breathing exercises assist with relaxation and pain relief during labor. Tai- lor sitting and squatting help stretch the perineal muscles in preparation for labor. CN: Health promotion and maintenance; CL: Analyze

106. Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? ■ 1. Limiting fl uid intake to 1 L daily to prevent overload. ■ 2. Emptying the bladder every 2 to 4 hours while awake. ■ 3. Washing the perineum with povidone iodine (Betadine) after voiding. ■ 4. Avoiding the intake of acidic fruit juices until the treatment is discontinued.

106. 2. The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep her bladder empty. In addition, she should main- tain adequate fl uid intake; 3,000 mL per day is recommended. Intake of acidic fruit juices (e.g., cranberry, apricot) is recommended because of their association with reducing the risk for infec- tion. The client should wear cotton underwear and avoid tight-fi tting slacks. She does not need to wash with povidone iodine (Betadine) after void- ing. Plain warm water is suffi cient to keep the perineal area clean. CN: Basic care and comfort; CL: Create

106. During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks' gesta- tion in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following? ■ 1. Congenital anomalies. ■ 2. Pulmonary hypertension. ■ 3. Meconium aspiration syndrome. ■ 4. Respiratory distress syndrome.

106. 4. Respiratory distress syndrome is more common in neonates delivered by cesarean section than in those delivered vaginally. During a vagi- nal delivery, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a cesarean delivery. Congenital anomalies are not more common with cesarean delivery. Pulmonary hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital diaphragmatic hernia, respira- tory distress syndrome, or neonatal sepsis, not with cesarean delivery. Meconium aspiration syndrome occurs more commonly with vaginal delivery, post- term neonate, and prolonged labor, not with cesar- ean delivery. CN: Health promotion and maintenance are; CL: Apply

107. A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intrave- nous ampicillin asks the nurse, "Can I still continue to breast-feed my baby?" The nurse should tell the client: ■ 1. "You can continue to breast-feed as long as you want to do so." ■ 2. "Alternate your breast-feeding with formula feeding to help you rest." ■ 3. "You'll need to discontinue breast-feeding until the antibiotic therapy is stopped." ■ 4. "You'll need to modify your technique by manually pumping your breasts."

107. 1. The client can continue to breast-feed as often as she desires. Continuation of breast-feeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breast- feeding mothers. Manual pumping of the breasts is not necessary. CN: Health promotion and maintenance; CL: Apply

23. After administering hydralazine (Apresoline) 5 mg intravenously as ordered for a primigravid cli- ent with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for: ■ 1. Tachycardia. ■ 2. Bradypnea. ■ 3. Polyuria. ■ 4. Dysphagia.

23. 1. One of the most common adverse effects of the drug hydralazine (Apresoline) is tachycar- dia. Therefore, the nurse should assess the client's heart rate and pulse. Hydralazine acts to lower blood pressure by peripheral dilation without interfering with placental circulation. Bradyp- nea and polyuria are usually not associated with hydralazine use. Dysphagia is not a typical adverse effect of hydralazine. CN: Pharmacological and parenteral therapies; CL: Analyze

107. On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse fi nds the client cry- ing. Which of the following comments by the nurse would be most appropriate? ■ 1. "Are you having a great deal of uterine pain?" ■ 2. "Commonly spontaneous abortion means a defective embryo." ■ 3. "I'm truly sorry you lost your baby." ■ 4. "You should try to get pregnant again as soon as possible."

107. 3. The death of a fetus at any time during preg- nancy is a tragedy for most parents. After a spontane- ous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I'm truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief pro- cess, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappro- priate because this is a "yes-no" question and doesn't allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus's demise. This is not the appropriate time to dis- cuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should get pregnant again as soon as possible is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus. CN: Psychosocial adaptation; CL: Apply

107. A 28-year-old multigravid client at 28 weeks' gestation diagnosed with acute pyelonephritis is receiving intravenous fl uids and antibiotics. After teaching the client about the rationale for the aggres- sive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following? ■ 1. Preterm labor. ■ 2. Maternal sepsis. ■ 3. Intrauterine growth retardation. ■ 4. Congenital fetal anomalies.

107. 4. Congenital anomalies are not related to maternal urinary tract infections. A multigravid client with acute pyelonephritis is susceptible to preterm labor, premature rupture of the membranes, maternal sepsis, intrauterine growth retardation, and fetal loss. The most common organism responsible for the urinary tract infection is Escherichia coli. CN: Reduction of risk potential; CL: Evaluate

108. A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following? ■ 1. Conjunctivitis. ■ 2. Heart disease. ■ 3. Harlequin sign. ■ 4. Brain damage.

108. 1. Conjunctivitis is a common complica- tion of neonates who are born to mothers with untreated chlamydial infection. Neonatal pneumo- nia is another condition associated with chlamydial infection of the mother. Untreated chlamydial infection is not associated with heart disease or brain damage. Exposure to rubella may lead to neonatal heart defects, and brain damage may occur as a result of prolonged shoulder dystocia or dif- fi culty delivering the fetal head during a vaginal breech delivery. Occasionally, because of immature circulation, a neonate who has been lying on his or her side appears red on one side of the body. This "harlequin sign" is transient and is of no clinical signifi cance. Presence of a harlequin sign is unre- lated to untreated chlamydial infection. CN: Reduction of risk potential; CL: Apply

109. A multigravid client who stands for long peri- ods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which of the following instructions would be helpful? ■ 1. Perform slow contraction and relaxation of the feet and ankles twice daily. ■ 2. Take frequent rest periods with the legs elevated above the hips. ■ 3. Avoid support hose that reach above the leg varicosities. ■ 4. Take a leave of absence from your job to avoid prolonged standing.

109. 2. The client with leg varicosities should take frequent rest periods with the legs elevated above the hips to promote venous circulation. The client should avoid constrictive clothing, but support hose that reach above the varicosities may help allevi- ate the pain. Contracting and relaxing the feet and ankles twice daily is not helpful because it does not promote circulation. Taking a leave of absence from work may not be possible because of economic reasons. The client should try to rest with her legs elevated or walk around for a few minutes every 2 hours while on the job. CN: Reduction of risk potential; CL: Synthesis

108. Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergon- ovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess: ■ 1. Blood pressure. ■ 2. Pulse rate. ■ 3. Breath sounds. ■ 4. Bowel sounds.

108. 1. Methylergonovine maleate (Methergine) can cause hypertension, so the nurse should assess the client's blood pressure before and after admin- istration. This drug should not be administered to clients who are hypertensive. Assessing pulse, respiration, and temperature is important for all postpartum clients to provide evidence of possible complications, such as infection. Tachycardia and diminished breath sounds are associated with pul- monary embolism, but these signs are not specifi c to methylergonovine (Methergine) administration. Assessing breath sounds would be important for a client who has had pregnancy-induced hypertension and received magnesium sulfate before delivery. However, by the fourth postpartum day, the effects of magnesium sulfate should have disappeared. Bowel sounds should be assessed after an operative delivery to determine whether peristalsis has begun so that the client can begin to drink clear liquids or eat soft foods. CN: Pharmacological and parenteral therapies; CL: Analyze

108. Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy? ■ 1. Keep the neonate's eyes completely covered. ■ 2. Use a regular diaper on the neonate. ■ 3. Offer feedings every 4 hours. ■ 4. Check the oral temperature every 8 hours.

108. 1. To prevent eye damage from phototherapy, the eyes must remain covered at all times while under the lights. The eye patches can be removed when the neonate is held out of the lights by the parents for feeding. Instead of a regular diaper, a "string" diaper or disposable face mask may be used to help contain loose stools, while allowing maxi- mum skin exposure. Feeding formula or breast milk every 2 to 3 hours is recommended to prevent hypo- glycemia and to encourage gastrointestinal motility. Because the phototherapy lights can overheat the neonate, the temperature should be checked by the axillary route every 2 to 4 hours. CN: Reduction of risk potential; CL: Apply

108. Rho(D) immune globulin (RhoGAM) is ordered for a client before she is discharged after a spontaneous abortion. The nurse instructs the cli- ent that this drug is used to prevent which of the following? ■ 1. Development of a future Rh-positive fetus. ■ 2. An antibody response to Rh-negative blood. ■ 3. A future pregnancy resulting in abortion. ■ 4. Development of Rh-positive antibodies.

108. 4. Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitiza- tion can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh- negative mothers do not develop sensitivities if the fetus is also Rh negative. CN: Pharmacological and parenteral therapies; CL: Apply

109. During the fi rst hour after delivery, assessment of a multiparous client who delivered a neonate weighing 4,593 g (10 lb, 2 oz) by cesarean delivery reveals a soft fundus with excessive lochia rubra. The nurse should include which of the following in the client's plan of care? ■ 1. Administration of intravenous oxytocin. ■ 2. Placement of the client in a side-lying position. ■ 3. Rigorous fundal massage every 5 minutes. ■ 4. Preparation for an emergency hysteromyo- mectomy.

109. 1. The client is exhibiting signs of early postpartal hemorrhage, defi ned as blood loss greater than 500 mL in the fi rst 24 hours postpar- tum. Rapid intravenous oxytocin infusion of 40 to 80 units in 1,000 mL of normal saline, oxygen therapy, and gentle fundal massage to contract the uterus are usually effective. If bleeding persists, the nurse should inspect the cervix and vagina for lacerations. Intramuscular or intravenous methylergonovine may be administered, but this drug elevates the blood pressure. Other phar- macologic interventions include prostaglandin (Hemabate, Prostin, PGF2α) I.M. and misoprostol (Cytotec) rectally or vaginally. Severe uncontrolled hemorrhage may require bimanual uterine com- pression, a dilation and curettage to remove any retained placental tissue, or a hysterectomy to pre- vent maternal death from hemorrhage. The client should be placed in the supine position to allow evaluation of the fundus. The side-lying position is not helpful in controlling postpartum hemorrhage. Vigorous fundal massage every 5 minutes is unnec- essary. In addition, it can be very painful for the mother. Rather, gentle massage along with oxytocin administration is used to stimulate the uterus to contract. A hysteromyomectomy is used to remove fi broid tumors. With massive hemorrhage, a hyster- ectomy (removal of the uterus) may be necessary to control the bleeding. CN: Health promotion and maintenance; CL: Create

109. A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin (RHIG) injection for which of the following reasons? ■ 1. To prevent Rh-positive sensitization with the next pregnancy. ■ 2. To provide active antibody protection for this pregnancy. ■ 3. To decrease the amount of Rh-negative sensi- tization for the next pregnancy. ■ 4. To destroy fetal Rh-positive cells during the next pregnancy.

109. 1. The purpose of the RHIG is to provide pas- sive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after delivery of an Rh- positive neonate. Clients who are Rh-negative and conceive an Rh-negative fetus do not need antibody protection. Rh-positive cells contribute to sensitiza- tion, not Rh-negative cells. The RHIG does not cross the placenta and destroy fetal Rh-positive cells. CN: Reduction of risk potential; CL: Apply

11. At which of the following locations would the nurse expect to palpate the fundus of a primipa- rous client immediately after delivery of a neonate? ■ 1. Halfway between the umbilicus and the sym- physis pubis. ■ 2. At the level of the umbilicus. ■ 3. Just below the level of the umbilicus. ■ 4. Above the level of the umbilicus.

11. 1. Immediately after delivery of the pla- centa, the nurse would expect to palpate the fundus halfway between the umbilicus and the symphy- sis pubis. Within 2 hours postpartum, the fundus should be palpated at the level of the umbilicus. The fundus remains at this level or may rise slightly above the umbilicus for approximately 12 hours. After the fi rst 12 hours, the fundus should decrease one fi ngerbreadth (1 cm) per day in size. By the ninth or tenth day, the fundus usually is no longer palpable. CN: Health promotion and maintenance; CL: Apply

11. Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a dia- phragm for family planning? ■ 1. Douching with an acidic solution after inter- course is recommended. ■ 2. Diaphragms should not be used if the client develops acute cervicitis. ■ 3. The diaphragm should be washed in a weak solution of bleach and water. ■ 4. The diaphragm should be left in place for 2 hours after intercourse.

11. 2. The teaching plan should include a cau- tion that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with in- creased incidence of urinary tract infections. Douch- ing after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermi- cidal jelly or cream should be used if intercourse is repeated during this period. CN: Reduction of risk potential; CL: Create

11. The nurse is teaching the mother of a new- born to develop her baby's sensory system. To fur- ther improve the infant's most developed sense, the nurse should instruct the mother to: ■ 1. Speak in a high-pitched voice to get the new- born's attention. ■ 2. Place the newborn about 12 inches from maternal face for best sight. ■ 3. Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. ■ 4. Give infant formula with a sweetened taste to stimulate feeding.

11. 3. Currently, the sense of touch is believed to be the most highly developed sense at birth. It is probably for this reason that neonates respond well to touch. Auditory sense typically is relatively imma- ture in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn his eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at approximately 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth. CN: Health promotion and maintenance; CL: Synthesize

11. When teaching a multigravid client diag- nosed with mild preeclampsia about nutritional needs, which of the following types of diet should the nurse discuss? ■ 1. High-residue diet. ■ 2. Low-sodium diet. ■ 3. Regular diet. ■ 4. High-protein diet.

11. 3. For clients with mild preeclampsia, a regular diet with ample protein and calories is rec- ommended. If the client experiences constipation, she should increase the fi ber in her diet, such as by eating raw fruits and vegetables, and increase fl uid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fl uid intake should not be restricted or increased. A high-protein diet is unnecessary. CN: Basic care and comfort; CL: Apply

11. A primigravid client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, which of the following would be the best position for the client to assume? ■ 1. Dorsal recumbent. ■ 2. Lithotomy. ■ 3. Hands and knees. ■ 4. Squatting.

11. 4. Anatomically, the best position for the client to assume is the squatting position because this enhances pelvic diameters and allows gravity to assist in the expulsion stage of labor. This posi- tion also provides for natural pressure anesthesia as the fetal presenting part presses on the stretched perineum. If the client is extremely fatigued from a lengthy labor process, she may prefer the dorsal recumbent position. However, this position is not considered the best position anatomically. The lithotomy position may be ineffective and uncom- fortable for a client who is ready to push. The hands and knees position may help to alleviate some back pain. However, this position can cause discomfort to the arms and wrists and is tiring over a long period of time. CN: Health promotion and maintenance; CL: Apply

110. A multigravid client at 36 weeks' gestation has been diagnosed with condylomata acuminata. Which of the following should the nurse include when teaching the client about the disorder and cur- rent therapies? ■ 1. Cryotherapy may be used to remove the warts. ■ 2. Podophyllin solution may be used to decrease the size of the warts. ■ 3. A 25% trichloroacetic acid solution can eradi- cate the disorder. ■ 4. Condylomata acuminata has been associated with ovarian cancer.

110. 1. Cryotherapy, electrocautery, or laser therapy may be used to remove the genital warts. Podophyllin solution should not be used to decrease their size while the client is pregnant, because fetal malformations may result. A 25% trichloroacetic acid solution can decrease the size of the warts, but because this disease is caused by a virus, the disor- der may recur. Condylomata acuminata has been as- sociated with cervical cancer, and the client should have semiannual or annual Pap smears to detect cervical dysplasia. CN: Pharmacological and parenteral therapies; CL: Create

110. The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peri- staltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomit- ing. The nurse notifi es the pediatrician because these signs are indicative of which of the following? ■ 1. Esophageal atresia. ■ 2. Pyloric stenosis. ■ 3. Diaphragmatic hernia. ■ 4. Hiatal hernia.

110. 2. Marked visible peristaltic waves in the abdomen and projectile vomiting are signs of pyloric stenosis. If the condition progresses without surgical intervention, the neonate will become dehydrated and develop metabolic alkalosis. Signs of esopha- geal atresia include coughing and regurgitation with feedings. Diaphragmatic hernia, a life-threatening event in which the abdominal contents herniate into the thoracic cavity, may be evidenced by breath sounds being heard over the abdomen and signifi - cant respiratory distress with cyanosis. Signs of hiatal hernia include vomiting, failure to thrive, and short periods of apnea. CN: Reduction of risk potential; CL: Analyze

14. When developing the plan of care for a primiparous client during the fi rst 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse's primary focus of care? ■ 1. The neonate. ■ 2. The family. ■ 3. The client's own comfort. ■ 4. The client's signifi cant other.

14. 3. The fi rst 12 hours after delivery are part of the taking-in phase of maternal postpartum adjustment, which typically lasts from 1 to 3 days. During the taking-in phase, the client is primar- ily concerned with her own needs. After the fi rst 1 to 3 days postpartum, the client is in the taking- hold phase and can focus more on the needs of the neonate. Although the family is an important unit of care and the signifi cant other is important for the mother's emotional support, during the taking-in phase the mother is focused on herself. CN: Health promotion and maintenance; CL: Analyze

110. A 16-year-old primigravid client admitted at 38 weeks' gestation with severe pregnancy-induced hypertension is given intravenous magnesium sul- fate and lactated Ringer's solution. The nurse should obtain which of the following information? ■ 1. Urinary output every 8 hours. ■ 2. Deep tendon refl exes every 4 hours. ■ 3. Respiratory rate every hour. ■ 4. Blood pressure every 6 hours.

110. 3. Because magnesium sulfate is a central nervous system depressant, the nurse should plan to assess the client's respiratory rate every hour. If the respiratory rate is less than 12 breaths/minute, the client may be experiencing magnesium sulfate overdose. Urinary output via an indwelling catheter should be assessed hourly and should be at least 30 mL/hour. Deep tendon refl exes and blood pres- sure should also be assessed every hour. At some institutions continuous electronic blood pressure monitoring will be performed. CN: Pharmacological and parenteral therapies; CL: Analyze

110. A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hem- orrhage at 1 hour after a cesarean delivery. The cli- ent asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following? ■ 1. Trauma during labor and delivery. ■ 2. Moderate fundal massage after delivery. ■ 3. Lengthy and prolonged second stage of labor. ■ 4. Overdistention of the uterus from hydramnios.

110. 4. The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uter- ine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and delivery can also contribute to uterine atony dur- ing the postpartum period. Trauma during labor and delivery is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean delivery for breech presentation. Therefore, it is unlikely that she had a long labor. CN: Physiological adaptation; CL: Apply

111. The labor and delivery room nurse has received a telephone call from the emergency room indicating that a multigravid client in early labor and diagnosed with probable placenta previa will be arriving soon. In preparation for the client's arrival, the nurse anticipates that the physician will order which of the following? ■ 1. Whole blood replacement. ■ 2. Continuous blood pressure monitoring. ■ 3. Internal fetal heart rate monitoring. ■ 4. An immediate cesarean delivery.

111. 2. For a client diagnosed with probable placenta previa, hypovolemic shock is a complica- tion. Continuous blood pressure monitoring with an electronic cuff is the priority assessment after the client's admission. Once the client is admitted, an ultrasound examination will be performed to deter- mine the placement of the placenta. Whole blood replacement is not warranted at this time. However, it may be necessary if the client demonstrates signs and symptoms of hemorrhage or shock. Internal fetal heart rate monitoring is contraindicated because the monitoring device may puncture the placenta and place both the mother and fetus in jeopardy. An immediate cesarean delivery is not necessary until there has been an assessment of the amount of bleeding and the location of the placenta previa. CN: Reduction of risk potential; CL: Apply

112. During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that she smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate assessment, the nurse should monitor the client for symptoms of which of the following? ■ 1. Placenta previa. ■ 2. Ruptured uterus. ■ 3. Maternal hypotension. ■ 4. Abruptio placentae.

112. 4. Dramatic vasoconstriction occurs as a result of sniffi ng crack cocaine. This can lead to increased respiratory and cardiac rates and hypertension. It can severely compromise placental circulation, resulting in abruptio placentae and preterm labor and delivery. Infants of these women can experience intracranial hemorrhage and withdrawal symptoms of tremulous- ness, irritability, and rigidity. Placenta previa, ruptured uterus, and maternal hypotension are not associated with cocaine use. Placenta previa may be associated with grand multiparity. Ruptured uterus may be asso- ciated with a large-for-gestational-age fetus. CN: Reduction of risk potential; CL: Analyze

111. The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following? ■ 1. Decreased cardiac output with faint periph- eral pulses. ■ 2. Profound cyanosis over most of the body. ■ 3. Loud cardiac murmurs through systole and diastole. ■ 4. Harsh systolic murmurs with a palpable thrill.

111. 3. With a patent ductus arteriosus, a cardiac defect marked by a failure of the patent ductus arte- riosus to close completely at birth, blood from the aorta fl ows into the pulmonary arteries to be reoxygen- ated in the lungs and returned to the left atrium and ventricle. The effect of this altered circulation includes increased workload on the left side of the heart and increased pulmonary vascular congestion. Term infants are commonly asymptomatic, but a loud, machinery-like murmur may be heard throughout systole and diastole. This murmur may be accom- panied by a suprasternal thrill, and the heart may be enlarged. Decreased cardiac output with faint peripheral pulses, poor peripheral perfusion, feed- ing diffi culties, and severe congestive heart failure are symptoms associated with severe aortic stenosis. With this defect, the aortic valve is thickened and rigid, leading to decreased cardiac output and reduced myocardial blood fl ow. Profound cyanosis over most of the body, fatigue on exertion, feeding diffi culties, and chronic hypoxemia are associated with tetralogy of Fallot. With this defect, malalignment of the ven- tricular system results in nonrestricted ventral septal defects, pulmonic stenosis, overriding of the aorta, and hypertrophy of the left ventricle. The heart appears boot shaped. A harsh systolic murmur with a palpable thrill is associated with truncus arteriosus. It is marked by incomplete division of the great vessel. This is caused by a ventral septal defect. Bounding pulses and a widening pulse pressure may also be present. CN: Reduction of risk potential; CL: Analyze

111. Thirty-six hours after a vaginal delivery, a multiparous client is diagnosed with endometritis due to b-hemolytic streptococcus. When assessing the client, which of the following would the nurse expect to fi nd? ■ 1. Profuse amounts of lochia. ■ 2. Abdominal distention. ■ 3. Nausea and vomiting. ■ 4. Odorless vaginal discharge.

111. 4. Scant and odorless vaginal discharge is associated with endometritis due to b-hemolytic streptococcus. The client also will exhibit "saw- tooth" temperature spikes between 101° and 104° F (38.3° to 40° C), tachycardia, and chills. The classic symptom of foul-smelling lochia is not associ- ated with this type of endometritis. Profuse and foul-smelling lochia is associated with classic endometritis from pathogens such as chlamydia or staphylococcus, not group B hemolytic streptococ- cus. Abdominal distention is associated with param- etritis as the pelvic cellulitis advances and spreads, causing severe pain and distention. Nausea and vomiting are associated with parametritis resulting from an abscess and advancing pelvic cellulitis. CN: Reduction of risk potential; CL: Analyze

111. A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed fl u- like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a physician because the nurse suspects which of the following sexually transmitted diseases? ■ 1. Gonorrhea. ■ 2. Chlamydia trachomatis infection. ■ 3. Syphilis. ■ 4. Herpes genitalis.

111. 4. The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal dis- charge. C. trachomatis infection in women is com- monly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The fi rst symptom of syphilis is a painless chancre. CN: Physiological adaptation; CL: Apply

112. A multiparous client visits the urgent care center 5 days after a vaginal delivery experienc- ing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, "Why am I con- tinuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following? ■ 1. Uterine atony. ■ 2. Cervical lacerations. ■ 3. Vaginal lacerations. ■ 4. Retained placental fragments.

112. 4. The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be scheduled for a dilatation and curet- tage to remove remaining placental fragments. Uterine atony, cervical lacerations, and vaginal lacerations are commonly associated with early, not late, postpartum hemorrhage. CN: Health promotion and maintenance; CL: Apply

112. Assessment of a term neonate at 8 hours after birth reveals tachypnea, dyspnea, sternal retrac- tions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifi es the pediatrician based on the interpretation that these symptoms are associated with which of the following? ■ 1. Coarctation of the aorta. ■ 2. Atrioventricular septal defect. ■ 3. Pulmonary atresia. ■ 4. Transposition of the great arteries.

112. 1. Coarctation of the aorta accounts for 5% to 7% of congenital heart disease. There is localized constriction of the aorta, at or near the insertion site of the ductus arteriosus, that increases after- load and decreases cardiac output. The infant with coarctation of the aorta presents with symptoms of poor lower body perfusion, metabolic acidosis, and congestive heart failure. Cyanosis is present in the lower part of the body because of decreased cardiac output. The child with a partial atrioven- tricular septal defect may be asymptomatic at birth. The symptoms in a child with a complete defect depend on the pulmonary artery pressure. If the pressure is high, the child will experience cyanosis on exertion; if it is low, congestive heart failure, manifested by tachypnea, dyspnea, and sternal retractions, may be present. The child with pul- monary atresia has profound (complete) cyanosis. On auscultation, the second heart sound is heard as a single sound. This is caused by failure of the pulmonary valve to develop and is accompanied by hypoplastic development of the pulmonary artery and right ventricle. Transposition of the great arter- ies is associated with complete cyanosis during the fi rst few hours of life. These infants demonstrate hypoxemia with a minimal response to oxygen. In this defect, the pulmonary and systemic systems exist in parallel. Systemic blood (unoxygenated) travels to the right atrium and right ventricle, then into the aorta. Pulmonary venous blood (oxygen- ated) recirculates through the left side of the heart and through the lungs. CN: Reduction of risk potential; CL: Analyze

112. While caring for a 24-year-old primigravid client scheduled for emergency surgery because of a probable ectopic pregnancy, the nurse should: ■ 1. Prepare to witness an informed consent for surgery. ■ 2. Assess the client for massive external bleeding. ■ 3. Explain that the fallopian tube can be salvaged. ■ 4. Monitor the client for uterine contractions.

112. 1. The client may need surgery to remove a ruptured fallopian tube where the pregnancy has oc- curred, and the nurse is usually responsible for wit- nessing the signature on the informed consent. Typi- cally, if bleeding is occurring, it is internal and there is only scant vaginal bleeding with no discoloration. The nurse cannot determine whether the fallopian tube can be salvaged; this can be accomplished only during surgery. If the tube has ruptured, it must be removed. If the tube has not ruptured, a linear salpingostomy may be done to salvage the tube for future pregnancies. With an ectopic pregnancy, although the client is experiencing abdominal pain, she is not having uterine contractions. CN: Physiological adaptation; CL: Synthesize

113. A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. The client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast. The client asks the nurse, "Can I continue breast- feeding?" The nurse should tell the client: ■ 1. "You can continue to breast-feed, feeding your baby more frequently." ■ 2. "You can continue once your symptoms begin to decrease." ■ 3. "You must discontinue breast-feeding until antibiotic therapy is completed." ■ 4. "You must stop breast-feeding because the breast is contaminated."

113. 1. The client being treated for infectious mastitis should continue to breast-feed often, or at least every 2 to 3 hours. Treatment also includes bed rest, increased fl uid intake, local heat application, analgesics, and antibiotic therapy. Continually emp- tying the breasts decreases the risk of engorgement or breast abscess. The client should not discontinue breast-feeding unless she chooses to do so. The client may continue breast-feeding while receiving antibiotic therapy. Generally, the breast milk is not contaminated by the offending organism and is safe for the neonate. CN: Physiological adaptation; CL: Synthesize

113. A 30-year-old G 4, P 3 client at 30 weeks' ges- tation is admitted to the hospital for evaluation. The client has experienced two neonatal deaths because of hemolytic disease of the newborn. An amniocen- tesis is to be performed to evaluate bilirubin density. The nurse should obtain a specimen container that is which of the following? ■ 1. Dark. ■ 2. Clear. ■ 3. Green. ■ 4. Amber.

113. 1. The optical density of the amniotic fl uid is evaluated for bilirubin level with a spectrophotom- eter. The higher the optical density, the more biliru- bin is present in the fl uid, indicating that fetal red blood cells are being destroyed. From these fi ndings, the severity of the disease can be estimated. Because light destroys bilirubin, specimens should be kept in a dark container until the analysis is complete. A clear, green, or amber container would allow light to enter, thus destroying bilirubin. CN: Reduction of risk potential; CL: Apply

113. A primigravid client in early labor tells the nurse that she was exposed to rubella at about 14 weeks' gestation. After delivery, the nurse should assess the neonate for which of the following? ■ 1. Hydrocephaly. ■ 2. Cardiac disorders. ■ 3. Renal disorders. ■ 4. Bulging fontanels.

113. 2. Pregnant women who become infected with the rubella virus early in pregnancy risk having a neonate born with rubella syndrome. The symp- toms include thrombocytopenia, cataracts, cardiac disorders, deafness, microcephaly, and motor and cognitive impairment. The most extensive neonatal effects occur when the mother is exposed during the fi rst 2 to 6 weeks and up to 12 weeks' gestation, when critical organs are forming. Bulging fontanels are associated with increased intracranial pressure and meningitis, which can occur as the result of a b-hemolytic streptococcal infection. CN: Reduction of risk potential; CL: Analyze

114. A primigravid client in early labor with abruptio placentae develops disseminated intra- vascular coagulation (DIC). Which of the following should the nurse expect the physician to order? ■ 1. Magnesium sulfate. ■ 2. Warfarin sodium (Coumadin). ■ 3. Fresh-frozen platelets. ■ 4. Meperidine hydrochloride (Demerol).

114. 3. To stop the process of DIC, the underlying insult that began the phenomenon must be halted. Treatment includes fresh-frozen platelets or blood administration. The physician also may order hepa- rin before the administration of blood products to restore the normal clotting mechanism. Immediate delivery of the fetus is essential. Magnesium sulfate is given for pregnancy-induced hypertension or pre- term labor. Heparin, not warfarin sodium (Couma- din), is used to treat DIC. Meperidine hydrochloride (Demerol) is used for pain relief. CN: Pharmacological and parenteral therapies; CL: Apply

113. The nurse is caring for a 2-day-old neonate in the recovery room 30 minutes after surgical cor- rection for the cardiac defect, transposition of the great vessels. Which of the following would alert the nurse to notify the physician? ■ 1. Oxygen saturation of 90%. ■ 2. Pale pink extremities. ■ 3. Warm, dry skin. ■ 4. Femoral pulse of 90 bpm.

113. 4. The normal pulse rate in a neonate is 120 to 160 beats per minute. Therefore, a femo- ral pulse rate of 90 bpm is too low. Diminished peripheral pulses, coolness and mottling of the extremities, delayed capillary refi ll, hypoten- sion, and decreased urine output are indicative of low cardiac output and poor perfusion. The neonate may be experiencing a complication of the surgery, such as blood loss or leaking of fl uid into the interstitial space. The surgeon should be notifi ed immediately to correct the diminished pulse, through either medications or transfusions. An oxygen saturation between 85% and 100% is considered normal. The surgeon does not need to be notifi ed unless the oxygen saturation falls below 85%. Pale pink extremities are considered a normal fi nding. If mottling or cyanosis devel- ops, the surgeon should be notifi ed immediately. Warm, dry skin is also a normal fi nding. If the skin becomes cool or appears cyanotic, the surgeon should be notifi ed. CN: Reduction of risk potential; CL: Synthesize

114. A primiparous client who had a vaginal delivery 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which of the following client state- ments indicates the need for additional teaching? ■ 1. "Down syndrome is an abnormality that can result from a missing chromosome." ■ 2. "Down syndrome usually results in some degree of mental retardation." ■ 3. "There are several methods available to deter- mine whether my baby has Down syndrome." ■ 4. "Older mothers are more likely to have a baby with chromosomal abnormalities."

114. 1. Down syndrome is a genetic abnormality that is caused by an extra chromosome that results in mental retardation. The degree of mental retar- dation is diffi cult to predict in a neonate, although most children born with Down syndrome have some degree of mental retardation. Various meth- ods can be used to determine whether a neonate has Down syndrome, which is commonly mani- fested by hypotonia, poor Moro reflex, fl at facial profile, upslanting palpebral fi ssures, epicanthal folds, and hyperfl exible joints. Genetic studies can be indicative of this disorder. Mothers older than 35 years of age are at a higher risk for having a child with Down syndrome. However, chromo- somal abnormalities can occur regardless of the mother's age. CN: Reduction of risk potential; CL: Evaluate

Managing Care Quality and Safety 114. The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrants prompt notifi cation of the health care provider and a further plan of care? ■ 1. Primigravida who reports fetal movement 6 times in 2 hours. ■ 2. Multigravida who had a positive oxytocin challenge test. ■ 3. Primigravida whose infant has a biophysical profi le of 9. ■ 4. Multigravida whose infant has a reactive non- stress test.

114. 2. Late decelerations during an oxytocin chal- lenge test indicate that the infant is not receiving enough oxygen during contractions and is exhib- iting signs of utero-placental insuffi ciency. This client would need further medical intervention. Fetal movement 6 times in 2 hours is adequate in a healthy fetus and a biophysical profi le of 9 indicates that the risk of fetal asphyxia is rare. A reactive non- stress test informs the health care provider that the fetus has 2 fetal heart rate accelerations of 15 beats per minute above baseline and lasting for 15 sec- onds within a 20-minute period, which is a reassur- ing result and an indication of fetal well-being. CN: Management of care; CL: Evaluate

114. After the physician explains the progno- sis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condi- tion, the nurse determines that the mother needs further instructions when she says which of the following? ■ 1. "As my child grows, she may have increased fatigue and diffi culty breathing." ■ 2. "My child may need to have antibiotics if she develops an infection." ■ 3. "This condition occurs more commonly in females than in males." ■ 4. "About half of the children born with this defect heal spontaneously."

114. 4. A child with atrial septal defect will be monitored by a cardiologist. Nonsurgical closure may be attempted via cardiac catheterization. Surgical closure, using either a prosthetic patch or sutures, is performed on an elective basis early in childhood. Children diagnosed with this disorder do not have spontaneous healing or closure. About 20% to 60% of children born with a ventricular sep- tal defect, an abnormal opening between the right and left ventricles, have spontaneous closure. Atrial septal defect accounts for approximately 10% of all congenital heart disease and is seen in more female than male neonates. This lesion consists of an abnormal opening between the atria. Ostium secun- dum, a defect located in the middle of the atrial septum, is the most common type seen. As the child grows, she may experience fatigue and dyspnea on exertion. A large defect may result in congestive heart failure if the lesion is unrepaired. Bacterial endocarditis prophylaxis with antibiotics may be ordered if the child develops an infection. CN: Reduction of risk potential; CL: Evaluate

115. A 15-year-old unmarried primiparous client is being cared for in the hospital's birthing center after vaginal delivery of a viable neonate. The neo- nate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the following responses would be most appropriate? ■ 1. "I'll bring the baby to you for feeding." ■ 2. "I think we should ask your physician if this is a good idea." ■ 3. "It's not a good idea for you to have any con- tact with the baby." ■ 4. "I'll check with the social worker to see if the adopting parents will permit this."

115. 1. After birth, the client should make the decision about how much she would like to partici- pate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The physician does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby. CN: Health promotion and maintenance; CL: Synthesize

115. A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: ■ 1. "Folic acid is important in preventing neu- ral tube defects in newborns and preventing anemia in mothers." ■ 2. "Eating foods with moderate amounts of folic acid helps regulate blood glucose levels." ■ 3. "Folic acid consumption helps with the absorption of iron during pregnancy." ■ 4. "Folic acid is needed to promote blood clotting and collagen formation in the newborn."

115. 1. Folic acid supplementation is recommend- ed to prevent neural tube defects and anemia in pregnancy. Defi ciencies increase the risk of hem- orrhage during delivery as well as infection. The recommended dose prior to pregnancy is 400 mcg/ day; while breast-feeding and during pregnancy, the recommended dosage is 500 to 600 mcg/day. Blood glucose levels are not regulated by the intake of folic acid. Vitamin C potentiates the absorption of iron and is also associated with blood clotting or colla- gen formation. CN: Reduction of risk potential; CL: Apply

Managing Care Quality and Safety 115. The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)? ■ 1. A neonate born at 36 weeks' gestation. ■ 2. A neonate born by Cesarean section. ■ 3. A neonate experiencing apneic episodes. ■ 4. A neonate who is 42 weeks' gestation

115. 1. The preterm infant is at greatest risk for developing RDS as the lungs are immature and unable to produce adequate surfactant to reduce the surface tension in the lungs and promote the stabil- ity of the alveoli. The neonate born at 42 weeks' ges- tation is at greater risk of having meconium stained amniotic fl uid and developing meconium aspiration syndrome. The neonate born by Cesarean section is at greater risk of fl uid retention in the lungs as the lungs were not compressed during the delivery process as they are in a vaginal delivery. Generally, these infants are able to overcome this situation with adequate crying. The infant experiencing apneic epi- sodes may be related to several conditions including hypothermia, sepsis, hypoglycemia and as a result of a rapid increase in the infant's temperature.

115. A multigravid client diagnosed with chronic hypertension is now in preterm labor at 34 weeks' gestation. The physician has ordered magnesium sulfate at 3 g/hour. Which assessment fi nding indicates that the intended therapeutic effect has occurred? ■ 1. Decrease in fetal heart rate accelerations. ■ 2. Decrease in the frequency and number of contractions. ■ 3. Decrease in maternal blood pressure rate. ■ 4. Decrease in maternal respiratory rate.

115. 2. The intended effect for this client is to decrease the number and frequency of contractions. Even though this client has chronic hypertension, the fi rst goal is to prevent delivery of a 34 weeks' gestation client. If the blood pressure moves into the therapeutic range, that is a benefi t for the client but it is not the major goal. Magnesium sulfate may decrease the accel- erations found in this fetus as it decreases the ability of the infant to respond, acting on the infant in the same way it does on the mother. Maternal respiratory rate may also decrease and a lower respiratory rate to 12 respirations per minute indicates that this level of magnesium sulfate is becoming toxic to this client. CN: Pharmacological and parenteral therapies; CL: Evaluate

116. A nurse is assigned to the obstetrical triage area. When beginning the assignment, the nurse is given a report about four clients waiting to be seen. Place the clients in the order in which the nurse should see them. 1. A primigravid client at 10 weeks' gestation complaining of not feeling well with nausea and vomiting, urinary frequency, and fatigue. 2. A multiparous client at 32 weeks' gesta- tion asking for assistance with fi nding a new physician. 3. A single mother at 4 months postpartum fear- ful of shaking her baby when he cries. 4. An antenatal client at 16 weeks' gestation who has occasional sharp pain on her left side radi- ating from her symphysis to her fundus.

116. 3. A single mother at 4 months postpartum fearful of shaking her baby when he cries. 4. An antenatal client at 16 weeks' gestation who has occasional sharp pain on her left side radi- ating from her symphysis to her fundus. 1. A primigravid client at 10 weeks' gestation complaining of not feeling well with nausea and vomiting, urinary frequency, and fatigue. 2. A multiparous client at 32 weeks' gestation ask- ing for assistance with fi nding a new physician. The fi rst client to be seen should be the postpartum mother who is fearful of shaking her infant. Postpar- tum depression is a disorder that may occur during the fi rst year postpartum but peaks at 4 weeks post- partum, prior to menses, or upon weaning. As a single mother, this client may not have support, a large factor putting women at risk. Other factors accentuat- ing risk include prior depressive or bipolar illness and self-dissatisfaction. Second, the nurse should see the 16-week antenatal client, who is likely experienc- ing round ligament syndrome. At this point in the pregnancy, the uterus is stretching into the abdomen causing this type of pain. The pain is on the wrong side to be attributed to appendicitis or gallbladder dis- ease. Nursing interventions to ease the pain include a heating pad or bringing the legs toward the abdo- men. The nurse should next see the primigravid client complaining of not feeling well because she is exhibit- ing signs and symptoms of discomfort experienced by most women in the fi rst trimester. The multiparous client at 32 weeks' gestation is the lowest priority as she is physically well, while the other clients have physical and psychological problems. In most emer- gency department situations, she may not be seen by medical or nursing staff but would be given the names of health care providers in the reception area. CN: Management of care; CL: Synthesize

116. A primigravid client who was successfully treated for preterm labor at 30 weeks' gestation had a history of mild hyperthyroidism before becoming pregnant. The nurse should instruct the client to do which of the following? ■ 1. Continue taking low-dose oral propylthioura- cil (PTU) as ordered. ■ 2. Discontinue taking the methimazole (Tapa- zole) until after delivery. ■ 3. Consider breast-feeding the neonate after the delivery. ■ 4. Contact the physician if bradycardia occurs.

116. 1. Although thioamides such as propylthio- uracil and methimazole are considered teratogenic to the fetus and can lead to congenital hyperthyroid- ism (goiter) in the neonate, they still represent the treatment of choice. The client should be regulated on the lowest possible dose. Hyperthyroidism is associated with preterm labor and a low-birth- weight infant, so the client should contact the physi- cian or health care provider if the contractions begin again. The client should not be urged to breast-feed, because medications such as propylthiouracil and methimazole are secreted in breast milk. Tachy- cardia (not bradycardia) is associated with thyroid storm, a medical emergency, and should be reported to the physician. CN: Pharmacological and parenteral therapies; CL: Apply

116. The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients fi rst? ■ 1. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes. ■ 2. A newborn delivered at 36-weeks' gestation weighing 5 lb who is due to breast-feed for the fi rst time in 15 minutes. ■ 3. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago. ■ 4. A newborn who had a borderline low temperature and was double-wrapped with a hat on 1⁄2 hour ago to bring up the temperature.

116. 3. The nurse should make rounds and fi rst assess the neonate with the respiratory rate of 62. The respiratory rate is out of the normal range and needs reevaluation. The newborn who is LGA still has 15 minutes before being due for the feeding and much can be accomplished by the nurse in that time. A 36-week newborn weighing 5 lb will need to be fed on time to maintain the blood glucose level. The nurse should next assess the infant with a borderline low temperature to determine if his body temperature is increasing. CN: Management of care; CL: Synthesize

116. After teaching a primiparous client about treat- ment and self-care of infectious mastitis of the right breast, the nurse determines that the client needs fur- ther instruction when she states which of the following? ■ 1. "I can apply localized heat to the infected area." ■ 2. "I should increase my fl uid intake to 2,000 mL per day." ■ 3. "I'll need to take antibiotics for 7 to 10 days before I am cured." ■ 4. "I should begin breast-feeding on the right side to decrease the pain."

116. 4. The client needs further instruction when she says that she should begin feeding on the right (painful) breast to decrease the pain. Starting the feeding on the unaffected (left) breast can stimu- late the milk ejection refl ex in the right breast and thereby decrease the pain. Frequent nursing or pumping is recommended to empty the breast. For some mothers, mastitis is so painful that they choose to discontinue breast-feeding, so these mothers need a great deal of support. Applying heat to the infected area before starting to feed is appropriate because heat stimulates circulation and promotes comfort. Increasing fl uid intake is advised to ensure adequate hydration. Antibiotics need to be taken until all medication has been used, usually 7 to 10 days to ensure eradication of the infection. CN: Reduction of risk potential; CL: Evaluate

117. The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One new- born is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notifi ed that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine follow-up. There can be no other addi- tions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation? ■ 1. Ask the nurses in SCN if they can take the newborn with possible sepsis now. ■ 2. Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms. ■ 3. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave. ■ 4. Ask the nurse with the infant who is breath- ing at 80 bpm to wait 1⁄2 hour.

117. 2. The nurse should manage this situation by asking the staff nurses to take at least one baby back to a room with a sleeping mother. This would allow the babies who are in need of care in the nursery to remain there. To maintain safety, the SCN can- not admit a client until they are prepared and have the staffi ng for this infant to be transferred. Social services can be called to determine if either of the newborns who have been referred to them can be dis- charged, but releasing these infants from the nursery will take several hours. It is unsafe to keep the infant with a respiratory rate of 80s waiting for a bed. CN: Management of care; CL: Create

119. A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, which of the following should the nurse do next? ■ 1. Administer oxygen by face mask. ■ 2. Begin cardiopulmonary resuscitation. ■ 3. Administer intravenous oxytocin. ■ 4. Obtain an order for intravenous fi brinogen.

119. 1. The client's symptoms are indicative of amniotic fl uid embolism, which is a medi- cal emergency. After calling for assistance, the fi rst action should be to administer oxygen by face mask or cannula to ensure adequate oxy- genation of mother and fetus. If the client needs cardiopulmonary resuscitation, this can be started once oxygen has been administered. If the client survives, disseminated intravascular coagulation will probably develop, and the client will need intravenous fi brinogen and heparin. Oxytocin, a vasoconstrictor, is not warranted for amniotic fl uid embolism. CN: Physiological adaptation; CL: Synthesize

117. During a home visit to a primiparous client who delivered vaginally 14 days ago, the client says, "I've been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just don't have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. Which of the following would be the nurse's best response? ■ 1. "These feelings commonly indicate symptoms of postpartum blues and are normal. They'll go away in a few days." ■ 2. "I think you're probably overreacting to the labor and delivery process. You're doing the best you can as a mother." ■ 3. "It's not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor." ■ 4. "This may be a symptom of a serious mental illness. I think you should probably go to the hospital."

117. 3. The client is probably experiencing postpartum depression, and the doctor should be contacted. Postpartum depression is usually treated with psychotherapy, social support groups, and antidepressant medications. Contributing factors include hormonal fl uctuations, a history of depres- sion, and environmental factors (e.g., job loss). An estimated 50% to 70% of women experience some degree of postpartum "blues," but these feelings of sadness disappear within 1 to 2 weeks after birth. However, the client is voicing more than just sad- ness. Telling her that she is overreacting is not helpful and may make her feel even less worthy. She is not exhibiting symptoms of a serious mental ill- ness (loss of contact with reality) and does not need hospitalization. CN: Health promotion and maintenance; CL: Synthesize

117. The health care provider at a prenatal clinic has ordered multivitamins for a woman who is 3 months' pregnant. The client calls the nurse to report that she has gone to the pharmacy to fi ll her prescription but is unable to buy it as it costs too much. The nurse should refer the client to: ■ 1. The charge nurse. ■ 2. The hospital fi nance offi ce. ■ 3. Her hospital social worker. ■ 4. Her insurance company.

117. 3. The social worker is available to assist the client in fi nding services within the community to meet client needs. This individual is able to provide the names of pharmacies within the community that offer generic substitutes or others that utilize the client's insurance plan. The charge nurse of the unit would be able to refer the client to the social worker. The hospital fi nance offi ce does not handle this type of situation and would refer the client back to the unit. The client's insurance company deals with payments for health care and would refer the client back to the local setting. CN: Management of care; CL: Apply

117. A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do fi rst? ■ 1. Pad the side rails of the client's bed. ■ 2. Turn the client to the right side. ■ 3. Insert a padded tongue blade into the client's mouth. ■ 4. Call for immediate assistance in the client's room.

117. 4. The fi rst action by the nurse should be to call for immediate assistance in the client's room, because this is an emergency. Throughout the seizure, the nurse should note the time and length of the seizure and continue to monitor the status of both client and fetus. The side rails should have been padded at the time of the client's admission to the hospital as part of seizure precautions. The client should be turned to her left side to improve placental perfusion. Inserting a tongue blade is not recommended because it can further obstruct the airway or cause injury to the client's teeth. CN: Safety and infection control; CL: Synthesize

118. The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met? ■ 1. Infant lying on abdomen. ■ 2. Security tags in place. ■ 3. Identifi cation system on mother and infant. ■ 4. Bulb syringe within sight. ■ 5. Someone in room able to care for infant. ■ 6. Infant in the mother's bed, side rails up. ■ 7. Infant in the mother's arms, both asleep.

118. 2,3,4, 5. A hospital-specifi c security system is the standard of care to prevent neonatal abduc- tion. The bulb syringe should be visible and easily accessible to both the mother and the nurse in case of choking. Someone should remain in the room who is able to safely care for the infant. This may be the mother or a family member if the mother is physi- cally not able to care for the infant. The infant should be lying on the back or side, rather than the abdomen to prevent sudden infant death syndrome ("back to sleep"). The infant should be in the mother's arms or in the crib rather than lying on a bed even with the side rails up as side rails do not prevent an infant from slipping through the rails. A sleeping mother in not aware of the status of the infant who can easily fall out of the mother's arms; the infant can be in the mother's arms only if she is awake. CN: Safety and infection control; CL: Evaluate

118. While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, "I want to leave him because I'm afraid he will hurt the baby." Which of the following actions is the nurse's most appropriate response? ■ 1. Tell the client to leave the boyfriend immediately. ■ 2. Ask the client when she last felt the baby move. ■ 3. Refer the client to a social worker for possible options. ■ 4. Report the incident to the unit nursing supervisor.

118. 3. In an abusive situation, the client's safety is the priority. The nurse should refer the client to a social worker who can provide the client with options such as a safe shelter. Commonly clients who are battered feel powerless and fear that the batterer will kill them. As a result, they remain in the abusive situation. Telling the client to leave the boyfriend immediately is not helpful and refl ects the values of the nurse. Although asking about fetal movement is important and is part of a routine assessment, a sonogram can be performed to confi rm fetal well-being. The referral is more important at this time. Although it may be part of the unit's policies and procedures to report any incidents such as this one to the unit supervisor, the client's immediate need for safety must be addressed fi rst. CN: Management of care; CL: Apply

Managing Care Quality and Safety 118. The nurse is catheterizing a client who can- not void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the cli- ent asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from fi rst to last. 1. Document incident. 2. Clean Betadine from client's vaginal area. 3. Notify physician ordering catheterization. 4. Ask client what her reaction is when exposed to Betadine. 5. File an incident report.

118. 4, 2, 3, 1, 5. The nurse should immediately ask the client what her reaction is as a result of the exposure to Betadine. This gives the nurse an idea of whether there needs to be preparation for an event as severe as cardiac arrest or as simple as skin irritation. The nurse should then clean the Betadine from the client, notify the physician of the incident, and ask for an order for medication if needed to counteract the Betadine. The nurse will need to document the incident on the client's chart as soon as the client has physically been taken care of. The nurse also will need to fi le an incident report. CN: Management of care; CL: Synthesize

119. A nurse is walking down the hall in the main corridor of a hospital. The Code Pink infant security alert system sounds and a Code Pink alert is announced. The fi rst responsibility of the nurse when this situation occurs is to do which of the fol- lowing? ■ 1. Move to the entrance of the hospital and check each person leaving. ■ 2. Go to the obstetrics unit to determine if they need help with the situation. ■ 3. Call the nursery to ask which baby is missing. ■ 4. Observe individuals in the area for large bags or oversized coats.

119. 4. The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the build- ing. Moving to the entrances and exits and checking each individual would be a responsibility of the doorman or security staff within the hospital sys- tem. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be avail- able. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information. CN: Safety and infection control; CL: Synthesize

12. A 17-year-old client at 33 weeks' gestation diagnosed with mild preeclampsia is prescribed bed rest at home. The nurse instructs the client to contact the health care provider immediately if she experiences which of the following? ■ 1. Blurred vision. ■ 2. Ankle edema. ■ 3. Increased energy levels. ■ 4. Mild backache.

12. 1. Severe headache, visual disturbances such as blurred vision, and epigastric pain are associated with the development of severe preec- lampsia and possibly eclampsia. These danger signs and symptoms must be reported immediately. Severe headache and visual disturbances are related to severe vasoconstriction and a severe in- crease in blood pressure. Epigastric pain is related to hepatic dysfunction. Ankle edema is common during the third trimester. However, facial edema is associated with increased fl uid retention and the progression from mild to severe preeclampsia. Increased energy levels are not associated with a progression of the client's preeclampsia or the de- velopment of complications. In fact, some women report an "energy spurt" before the onset of labor. Mild backache is a common discomfort of preg- nancy, unrelated to a progression of the client's preeclampsia. It also may be associated with bed rest when the mattress is not fi rm. Some multipa- rous women have reported a mild backache as a sign of impending labor. CN: Reduction of risk potential; CL: Synthesize

12. While making a home visit to a primiparous client and her 3-day-old son, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powder to the neonate's buttocks. Which of the following statements about baby powder should the nurse relate to the mother? ■ 1. It may cause pneumonia to develop. ■ 2. It helps prevent diaper rash. ■ 3. It keeps the diaper from adhering to the skin. ■ 4. It can result in allergies later in life.

12. 1. The nurse should inform the mother that baby powder can enter the neonate's lungs and result in pneumonia secondary to aspiration of the particles. The best prevention for diaper rash is frequent diaper changing and keeping the neonate's skin dry. The new disposable diapers have moisture- collecting materials and generally do not adhere to the skin unless the diaper becomes saturated. Typically, allergies are not associated with the use of baby powder in neonates. CN: Reduction of risk potential; CL: Synthesize

12. When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following? ■ 1. Chorioretinitis from cytomegalovirus. ■ 2. Blindness secondary to gonorrhea. ■ 3. Cataracts from beta-hemolytic streptococcus. ■ 4. Strabismus resulting from neonatal maturation.

12. 2. The instillation of erythromycin into the neonate's eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonor- rhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate's eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial men- ingitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effec- tive for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age. CN: Pharmacological and parenteral therapies; CL: Apply

12. A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis? ■ 1. Impaired urinary elimination related to nothing-by-mouth status. ■ 2. Risk for injury related to hyperventilation and dizziness. ■ 3. Ineffective coping related to lack of confi - dence. ■ 4. Pain related to increasing frequency and intensity of uterine contractions.

12. 4. During transition, contractions are increas- ing in frequency, duration, and intensity. The most appropriate nursing diagnosis is Pain related to strength and duration of the contractions. Insuf- fi cient information is provided in the scenario to support the other listed nursing diagnoses. Impaired urinary elimination would be appropriate if the cli- ent had a full bladder and was unable to void. Risk for injury might apply if the client were completely out of control or thrashing around in the bed. Inef- fective coping might apply if the client said, "I can't do this" or something similar. CN: Health promotion and maintenance; CL: Analyze

12. After being examined and fi tted for a dia- phragm, a 24-year-old client receives instructions about its use. Which of the following client state- ments indicates a need for further teaching? ■ 1. "I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case." ■ 2. "If I get pregnant, I will have to be refi tted for another diaphragm after the delivery." ■ 3. "Before inserting the diaphragm I should coat the rim with contraceptive jelly." ■ 4. "If I gain or lose 20 lb, I can still use the same diaphragm."

12. 4. The client would need additional instruc- tions when she says that she can still use the same diaphragm if she gains or loses 20 lb. Gaining or losing more than 15 lb can change the pelvic and vaginal contours to such a degree that the dia- phragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case. The client should be refi tted for another diaphragm after pregnancy and delivery of a newborn be- cause weight changes and physiologic changes of pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm. The client should use a spermicidal jelly or cream before inserting the diaphragm. CN: Reduction of risk potential; CL: Evaluate

120. The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.? (pic) ■ 1. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change. ■ 2. Start IV of D5 1⁄2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift. ■ 3. Complete admission assessment of newborn turned over to nurse at 5 a.m. ■ 4. Draw newborn bilirubin level at 6 a.m.

120. 5:00 - 3 5:30 - 1 6:00 - 4 6:30 - 2 Drawing the bilirubin levels at 6 a.m. must occur at a specifi c time. The admission assessment should be completed as soon after admission as possible; 5 a.m. is available to complete this task. The IV should be started at 6:30 and completed as close to change of shift as possible. The nurse should then draw the blood at 5:30 a.m., right after the newborn assessment. CN: Management of care; CL: Create

Managing Care Quality and Safety 120. The nurse is working on a busy labor and delivery unit with other nurses and a licensed practical nurse. Which of the following labor clients would the nurse assign to the licensed practical nurse? ■ 1. A G 4, P 3 client with a history of gestational diabetes. ■ 2. A G 3, P 1, Ab 1 client at 35 weeks' gestation. ■ 3. A G 1, P 0 client with leaking green amniotic fl uid. ■ 4. A G 2, P 1 client with a history of hyperem- esis gravidarum.

120. 4. Delegation of duties and clients to ancil- lary personnel is commonly the responsibility of the registered nurse. The client who is a G 2, P 1, with a history of hyperemesis gravidarum, is the client with the least potential for labor complications. Hyperemesis gravidarum typically occurs and is treated in the fi rst or second trimester of pregnancy and should be resolved by this point in the preg- nancy. A G 4, P 3 client with a history of gestational diabetes may have cephalopelvic disproportion due to a large-for-gestational-age fetus requiring a cesarean section delivery. The G 3, P 1, Ab 1 client is preterm at 35 weeks' gestation and may require an intensive care neonatal team. In a G 1, P 0 client, leaking green amniotic fl uid indicates that there has been fetal distress. CN: Management of care; CL: Synthesize

123. The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client fi rst? ■ 1. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural. ■ 2. A primipara who is 100% effaced, 8 cm dilated, + 2 station complaining of nausea. ■ 3. A client with no prenatal care, occasional contractions, BP 148/90, c/o and swollen feet. ■ 4. A client who is at 42 weeks' gestation with bloody show, no contractions, ROM 1 hour ago leaking green fl uid.

123. 4. The client at 42 weeks' is the greatest concern and the nurse should make rounds on this client fi rst based on the length of the pregnancy and the green color of the amniotic fl uid. Bloody show is a normal sign of impending labor as the cervix may be beginning to dilate. Not having contractions after rupture of membranes is not unusual within a 1-hour time frame. The green amniotic fl uid indi- cates that fetal distress has recently occurred to the point that the fetus had a bowel movement in utero. Along with the 42-week gestation, this fetus is at greatest risk. The nurse can see the primipara in active labor at 5 cm dilation last; this client is in pain but nothing about her situation indicates anything but a normal labor process and as a primi- para, her labor process will be slow. The client that is completely effaced, 8 cm dilated and at + 2 station as a primipara usually moves through labor at a slower pace than a multiparous client. She is experiencing nausea which is an expected situa- tion as a laboring client enters transition. The client with no prenatal care is a cause for concern as the nurse knows nothing about her background. Her blood pressure is elevated, an indicator of mild preeclampsia, but there is no other indications of worsening preeclampsia, such as headache, visual disturbances, or epigastric pain. CN: Management of care; CL: Synthesize

121. The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unli- censed nursing personnel? ■ 1. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin. ■ 2. A G4 P4 who is breast-feeding an 8 lb infant without diffi culty. ■ 3. A G3 P3 postpartum client who is receiving Magnesium Sulfate and whose infant has a respiratory rate of 20. ■ 4. A G2 P2 who delivered vaginally 2 days ago with an infant having low blood glucose lev- els the fi rst 24 hours post delivery.

121. 2. The client who is a G4 P4 can be cared for by the CNA II. There are no indications that there are any problems with this couplet and the assess- ments have been completed by the RN. The client with gestational diabetes will need specifi c assess- ments, medications, and potentially other actions based on recent delivery. Her infant is within the fi rst 24 hours of delivery when infants of gestational diabetics often drop their blood glucose levels and this will require frequent assessment and possible interventions. The client who is G3 P3 postpartum and receiving Magnesium Sulfate must be cared for by a registered nurse. The respiratory rate of this client's infant is borderline low and often is related to the administration of Magnesium Sulfate and should receive a higher level of nursing care. The client who is a G2 P2, with an infant with docu- mented low blood sugars, will require assessment and potential intervention if the blood sugar levels change; only registered nurses can safely manage this care. CN: Management of care; CL: Synthesize

121. A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should: ■ 1. Ask her to remain in bed until the 15-minute assessments are complete. ■ 2. Assess client's ability to stand and bear weight before going to the bathroom. ■ 3. Encourage the client to sit at the side of the bed before ambulating to the bathroom. ■ 4. Ask the client to ambulate the fi rst time with a staff member at her side.

121. 2. The nurse will need to assess the client's ability to bear weight before taking her to the bath- room. If she cannot bear weight, she will be unable to ambulate. Asking the client to remain in bed until the assessments are complete sets the client up for increased post partum bleeding, as the blad- der will displace the uterus. Encouraging the client to sit at the bedside is an excellent strategy to prevent orthostatic hypotension, but will not give the nurse an idea if the client can ambulate. Hav- ing a staff member with the client is also correct for the fi rst ambulation of this client, but the ability to bear weight and walk will need to be completed first. CN: Reduction of risk potential; CL: Syntheisze

122. The charge nurse is preparing for the day shift on the Labor and Delivery unit. Which of the following would be included in the responsibilities for this position? Select all that apply. ■ 1. Review the current status of each labor client with the primary nurse. ■ 2. Admit the new labor client sent from the triage area. ■ 3. Complete the work of the nurse who had to leave 30 minutes early. ■ 4. Follow up with the primary nurse after a delivery. ■ 5. Complete report of unit with the oncoming charge nurse.

122. 1, 4, 5. In most settings, the charge nurse coordinates and directs the activities of the unit. Prior to the change of shift, the nurse will review and update the status of each of the laboring clients on the unit to include any diffi culties or unusual situations that may be occurring with each of them, including following up with a primary nurse after a delivery. A change of shift report with the oncoming charge nurse is among the last activities completed before ending the shift. Activities such as admitting a client in labor and completing the nursing respon- sibilities of the nurse who had to leave 30 minutes early can be delegated to staff members. In an emergency situation, the charge nurse could assume responsibility for client care. CN: Management of care; CL: Create

124. The triage nurse is giving a telephone report to the receiving nurse in the labor and delivery unit. The client is a G4 P3 who is 8 cm dilated and is being transferred to the labor and delivery unit. How should the labor and delivery nurse manage the next ten minutes with the client? Select all that apply. ■ 1. Place client on the fetal and contraction monitor. ■ 2. Call other staff to set up the delivery table. ■ 3. Assess comfort needs of client. ■ 4. Determine support systems for client. ■ 5. Prepare to give an early report to the nurse arriving on the next shift.

124. 1, 2, 3, 4. Assuring the safety of this client is the top priority for this client. The nurse should place the client on the fetal and contraction moni- tor. Since the client is 8 cm dilated and a multi- gravid client, asking other staff members to set up the delivery table would be in order. This client is not a candidate for medication as this may have an infl uence on the baby. This client is past the point of offering an epidural as she may have delivered by the time the medication is in effect, but com- fort measures such as warm or cool cloths, back rubs, etc. may be helpful. The support system is an important aspect of the delivery process and is an easily settled situation. Preparing to give an early report to the oncoming nurse does not apply in this situation. CN: Management of care; CL: Create

125. A client has experienced a post partum hemorrhage. The physician verbally ordered 0.2 mg Methergine IM stat at the time of the hemorrhage and this was given by the nurse. The physician put an order into the electronic medical record for 0.2 mg Methergine by mouth stat. When seeing the order, how should the nurse administering the Methergine respond? ■ 1. Ask the charge nurse to have a discussion with the physician about the order. ■ 2. Initiate an incident report. ■ 3. Call the physician; discuss the order, and request revision if heard correctly. ■ 4. Wait until the physician returns to the unit and discuss the situation in person.

125. 3. In emergency situations, verbal orders should be entered into the electronic medical record or chart and signed immediately after the emer- gency. The nurse taking this order and giving the medication needs to call the physician, explain the order and that the medication was administered per the verbal order, and request that the physician write the correct order. If the nurse misunderstood the order and gave the medication by the wrong route, an incident report will need to be initiated. The charge nurse would become involved if an error has occurred, an incident report is needed, or there is diffi culty between the nurse and physician that cannot be remediated. Rectifying this order is the responsibility of the implementing nurse. Waiting until the physician comes back to the hospital unit may not occur quickly enough to safely care for the client. CN: Management of care; CL: Synthesize

13. A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the inci- dence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods? Select all that apply. ■ 1. Leafy green vegetables. ■ 2. Strawberries. ■ 3. Beans. ■ 4. Milk. ■ 5. Sunfl ower seeds. ■ 6. Lentils.

13. 1,2,3,5,6. The pregnancy requirement for folic acid is 600 micrograms/day. Major sources of folic acid include leafy green vegetables, straw- berries and oranges, beans, particularly black and kidney beans, sunfl ower seeds, and lentils. Milk and fats contain no folic acid. CN: Health promotion and maintenance; CL: Apply

13. A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? ■ 1. The cord lengthens outside the vagina. ■ 2. There is decreased vaginal bleeding. ■ 3. The uterus cannot be palpated. ■ 4. Uterus changes to discoid shape.

13. 1. The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes more fi rm and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage. CN: Health promotion and maintenance; CL: Analyze

13. One week after her prenatal visit, a primi- gravid client at 38 weeks' gestation diagnosed with mild pre-eclampsia calls the clinic nurse complain- ing of a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client: ■ 1. "Take two acetaminophen tablets. They aren't as likely to upset your stomach." ■ 2. "I think the doctor should see you today. Can you come to the clinic this morning?" ■ 3. "You need to lie down and rest. Have you tried placing a cool compress over your head?" ■ 4. "I'll ask the doctor to call in a prescription for aspirin with codeine. What's your pharmacy's number?"

13. 2. A client with preeclampsia complaining of a continuous headache for 2 days should be seen by a health care provider immediately. Continuous headache, drowsiness, and mental confusion indi- cate poor cerebral perfusion and are symptoms of se- vere preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Aspirin with codeine may temporarily relieve the client's headache. However, this delays immediate treatment, which is crucial. Additionally, pregnant women are advised not to take aspirin at this time because it may cause clotting problems in the neonate. Codeine generally is not prescribed. CN: Reduction of risk potential; CL: Synthesize

13. The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following? ■ 1. Hypoglycemia. ■ 2. Hyperbilirubinemia. ■ 3. Hemorrhage. ■ 4. Polycythemia.

13. 3. Phytonadione (vitamin K or AquaMEPHY- TON) acts as a preventive measure against neonatal hemorrhagic disease. At birth, the neonate does not have the intestinal fl ora to produce vitamin K, which is necessary for coagulation. Hypoglycemia is pre- vented and treated by feeding the infant. Hyperbili- rubinemia severity can be decreased by early feeding and passage of meconium to excrete the bilirubin. Hyperbilirubinemia is treated with phototherapy. Polycythemia may occur in neonates who are large for gestational age or post-term. Clamping of the umbilical cord before pulsations cease reduces the incidence of polycythemia. Generally, polycythemia is not treated unless it is extremely severe. CN: Pharmacological and parenteral therapies; CL: Apply

13. After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which of the following statements by the mother indicates to the nurse that the mother needs addi- tional instructions? ■ 1. "The petroleum gauze may fall off into the diaper." ■ 2. "A few drops of blood oozing from the site is normal." ■ 3. "I'll leave the gauze in place for 24 hours." ■ 4. "I'll remove any yellowish crusting gently with water."

13. 4. The mother needs further instruction when she says that a yellowish crust should be removed with water. The yellowish crust is normal and indicates scar formation at the site. It should not be removed, because to do so might cause increased bleeding. The petroleum gauze prevents the diaper from sticking to the circumcision site, and it may fall off in the diaper. If this occurs, the mother should not attempt to replace it but should simply apply plain petroleum jelly to the site. The gauze should be left in place for 24 hours, and the mother should continue to apply petroleum jelly with each diaper change for 48 hours after the pro- cedure. A few drops of oozing blood is normal, but if the amount is greater than a few drops the mother should apply pressure and contact the physician. Any bleeding after the fi rst day should be reported. CN: Reduction of risk potential; CL: Evaluate

14. A couple is inquiring about vasectomy as a permanent method of contraception. Which teach- ing statement would the nurse include in the teach- ing plan? ■ 1. "Another method of contraception is needed until the sperm count is 0." ■ 2. "Vasectomy is easily reversed if children are desired in the future." ■ 3. "Vasectomy is contraindicated in males with prior history of cardiac disease." ■ 4. "Vasectomy requires only a yearly follow-up once the procedure is completed."

14. 1. Another method of contraception is needed until all sperm has been cleared from the body. The number of ejaculates for this to occur varies with the individual and laboratory analysis is required to determine when that has been ac- complished. Vasectomy is considered a permanent sterilization procedure and requires microsurgery for anastomosis of the vas deferens to be completed. Studies have shown that there is no connection between cardiac disease in males and vasectomy. There is no need for follow-up once verifi cation there is no sperm in the system. CN: Physiological adaptation; CL: Create

14. When assessing a 16-year-old primigravid client at 37 weeks' gestation diagnosed with severe preeclampsia, which of the following indicates the client needs continued management for the preec- lampsia? ■ 1. Blood pressure of 138/94 mm Hg. ■ 2. Severe blurring of vision. ■ 3. Less than 2 g of protein in a 24-hour sample. ■ 4. Weight gain of 0.5 lb in 1 week.

14. 2. Signs of severe preeclampsia include blood pressure of 160/110 mm Hg or greater mea- sured at two different times at least 6 hours apart, severe blurring of vision or seeing spots in front of the eyes, oliguria, proteinuria of 5 g or greater in a 24-hour specimen, a serum creatinine concentration of 1.2 mL/dL, and a urine specifi c gravity of 1.04 or greater. A blood pressure of 138/94 mm Hg would suggest mild preeclampsia, as would proteinuria of less than 2 g in a 24-hour urine specimen. A weight gain of 1 lb per week in the third trimester is nor- mal. However, a weight gain of 2 lb or more suggests severe preeclampsia. CN: Physiological adaptation; CL: Synthesize

14. A primiparous client, who has just delivered a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following? ■ 1. Disappointment in the baby's gender. ■ 2. Grief over the ending of the pregnancy. ■ 3. A normal response to the birth. ■ 4. Indication of postpartum "blues."

14. 3. Childbirth is a very emotional experience. An expression of happiness with tears is a normal reaction. Cultural factors, exhaustion, and anxieties over the new role can all affect maternal responses, so the nurse must be sensitive to the client's emotional expressions. There is no evidence to suggest that the mother is disappointed in the baby's gender, griev- ing over the end of the pregnancy, or a candidate for postpartum "blues." However, approximately 80% of postpartum clients experience transient postpartum blues several days after delivery. CN: Health promotion and maintenance; CL: Analyze

14. After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neo- nate exhibits which of the following? ■ 1. Ability to fall asleep easily after each feeding. ■ 2. Spitting up of a tablespoon of formula after feeding. ■ 3. Passage of a liquid stool with a watery ring. ■ 4. Production of one to two light brown stools daily.

14. 3. The mother demonstrates understanding of the discharge instructions when she says that she should contact the pediatrician if the baby has a liquid stool with a watery ring, because this indi- cates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehy- dration. Normally, babies fall asleep easily after a feeding because they are satisfi ed and content. Spit- ting up a tablespoon of formula is normal. However, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day. CN: Reduction of risk potential; CL: Evaluate

15. The nurse instructs a primiparous client about bottle-feeding her neonate. Which of the following demonstrates that the mother has under- stood the nurse's instructions? ■ 1. Placing the neonate on his back after the feed- ing. ■ 2. Bubbling the baby after 1 oz of formula. ■ 3. Putting three-fourths of the bottle nipple into the baby's mouth. ■ 4. Pointing the nipple toward the neonate's palate.

15. 1. Placing the neonate on his back after the feeding is recommended to minimize the risk for sudden infant death syndrome (SIDS). Placing the neonate on the abdomen after feeding has been asso- ciated with SIDS. The mother should bubble or burp the baby after 1⁄2 oz of formula has been taken and then again when the baby is fi nished. Waiting until the baby has eaten 1 oz of formula can lead to regur- gitation. The entire nipple should be placed on top of the baby's tongue and into the mouth to prevent excessive air from being swallowed. The nipple is pointed directly into the mouth, not toward the neo- nate's palate, to provide adequate sucking. CN: Reduction of risk potential; CL: Evaluate

15. The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal delivery. The nurse should next: ■ 1. Apply an ice pack to the perineal area. ■ 2. Assess the client's temperature. ■ 3. Have the client take a warm sitz bath. ■ 4. Contact the physician for orders for an antibiotic.

15. 1. The client has a hematoma. During the fi rst 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the fi rst 24 hours. Although vital signs, including temperature, are important assessments, taking the client's tem- perature is unrelated to the hematoma and would provide no additional information about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effec- tive way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve with- out further treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide a baseline for subsequent measurements and should notify the physician of its presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or symptoms of infection. CN: Health promotion and maintenance; CL: Synthesize

15. A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client state- ments indicates effective teaching? ■ 1. "My fallopian tubes will be tied off through a small abdominal incision." ■ 2. "Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%." ■ 3. "After this procedure, I must abstain from intercourse for at least 3 weeks." ■ 4. "Both of my ovaries will be removed during the tubal ligation procedure."

15. 1. Tubal ligation, a female sterilization pro- cedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy). Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the cli- ent may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries. CN: Health promotion and maintenance; CL: Evaluate

15. The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and con- tractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time? ■ 1. Resting in the right lateral recumbent posi- tion. ■ 2. Lying in the left lateral recumbent position. ■ 3. Walking around in the hallway. ■ 4. Sitting in a comfortable chair for a period of time.

15. 3. Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single-room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walk- ing can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus. CN: Health promotion and maintenance; CL: Synthesize

15. When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain? ■ 1. Oxytocin infusion solution. ■ 2. Disposable tongue blades. ■ 3. Portable ultrasound machine. ■ 4. Padding for the side rails.

15. 4. The client with severe preeclampsia may develop eclampsia, which is characterized by sei- zures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. How- ever, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority. CN: Physiological adaptation; CL: Apply

16. The physician orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gesta- tion diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside? ■ 1. Diazepam (Valium). ■ 2. Hydralazine (Apresoline). ■ 3. Calcium gluconate. ■ 4. Phenytoin (Dilantin).

16. 3. The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women. Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures. CN: Pharmacological and parenteral therapies; CL: Apply

16. Which of the following would the nurse include in the teaching plan for a 16-year-old primi- gravid client in early labor concerning active relax- ation techniques to help her cope with pain? ■ 1. Relaxing uninvolved body muscles during uterine contractions. ■ 2. Practicing being in a deep, meditative, sleep- like state. ■ 3. Focusing on an object in the room during the contractions. ■ 4. Breathing rapidly and deeply between contractions.

16. 1. Childbirth educators use various techniques and methods to prepare parents for labor and deliv- ery. Active relaxation involves relaxing uninvolved muscle groups while contracting a specifi c group and using chest breathing techniques to lift the diaphragm off the contracting uterus. A deep, meditative, sleep- like state is a form of passive relaxation. Focusing on an object in the room is part of Lamaze technique for distraction. Breathing rapidly and deeply can lead to hyperventilation and is not recommended. CN: Health promotion and maintenance; CL: Synthesize

16. The nurse is to draw a blood sample for glucose testing from a term neonate during the fi rst hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas? (pic)

16. 1. In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood specimen. Using this area prevents damage to the calcaneus bone, which is located in the middle of the heel. The middle of the heel is to be avoided because of the increased risk for damaging the cal- caneus bone located there. The middle of the foot contains the medial plantar nerve and the medial plantar artery, which could be injured if this site is selected. Using the base of the big toe as the site for specimen collection would cause a great deal of discomfort for the neonate; therefore, it is not the preferred site. CN: Reduction of risk potential; CL: Apply

16. A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following? ■ 1. Check the cervical mucus to see if it is thick and sparse. ■ 2. Take her temperature at the same time every morning before getting out of bed. ■ 3. Document ovulation when her temperature decreases at least 1° F. ■ 4. Avoid coitus for 10 days after a slight rise in temperature.

16. 2. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the tem- perature falls by 0.5° F. At the time of ovulation, the temperature rises 0.4° to 0.8° F because of increased progesterone secretion in response to the luteiniz- ing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the fi rst 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy. CN: Health promotion and maintenance; CL: Apply

16. Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the cli- ent with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, fi nding it distended. The nurse interprets this fi nding based on the understanding that the client's bladder distention is most likely caused by which of the following? ■ 1. Prolonged fi rst stage of labor. ■ 2. Urinary tract infection. ■ 3. Pressure of the uterus on the bladder. ■ 4. Edema in the lower urinary tract area.

16. 4. Urinary retention soon after delivery is usually caused by edema and trauma of the lower urinary tract; this commonly results in diffi culty with initiating voiding. Hyperemia of the bladder mucosa also commonly occurs. The combination of hyper- emia and edema predisposes to decreased sensation to void, overdistention of the bladder, and incomplete bladder emptying. A prolonged fi rst stage of labor can contribute to exhaustion and uterine atony, not urinary retention. If the client had a urinary tract infection, she would exhibit symptoms such as dysuria and a burn- ing sensation. After delivery, the uterus is contracting, which leads to less pressure on the bladder. Pressure of the uterus on the bladder occurs during labor. CN: Health promotion and maintenance; CL: Analyze

17. For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment fi ndings would alert the nurse to suspect hypermagnesemia? ■ 1. Decreased deep tendon refl exes. ■ 2. Cool skin temperature. ■ 3. Rapid pulse rate. ■ 4. Tingling in the toes.

17. 1. Typical signs of hypermagnesemia include decreased deep tendon refl exes, sweating or a fl ush- ing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity in- creases. The nurse should check the client's patellar, biceps, and radial refl exes regularly during magne- sium sulfate therapy. Cool skin temperature may re- sult from peripheral vasodilation, but the opposite— fl ushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia. CN: Physiological adaptation; CL: Analyze

17. After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following? ■ 1. Antibacterial soap. ■ 2. Warm water. ■ 3. Povidone-iodine (Betadine) solution. ■ 4. Diluted hydrogen peroxide.

17. 2. After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide may cause pain and is not recommended. Povidone- iodine solution may cause stinging and burning, and therefore its use is not recommended. CN: Health promotion and maintenance; CL: Apply

17. A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate? ■ 1. "Your menstrual cycle will return in 3 to 4 weeks." ■ 2. "It will probably be 6 to 10 weeks before it starts again." ■ 3. "You can expect your menses to start in 12 to 14 weeks." ■ 4. "Your menses will return in 16 to 18 weeks."

17. 2. For clients who are bottle-feeding, the menstrual fl ow should return in 6 to 10 weeks, after a rise in the production of follicle-stimulating hormone by the pituitary gland. Nonlactating moth- ers rarely ovulate before 4 to 6 weeks postpartum. Therefore, 3 to 4 weeks is too early for the menstrual cycle to resume. For women who are breast-feeding, the menstrual fl ow may not return for 3 to 4 months (12 to 16 weeks) or, in some women, for the entire period of lactation, because ovulation is suppressed. CN: Health promotion and maintenance; CL: Apply

17. The nurse is performing effl eurage for a primigravid client in early labor. The nurse should do which of the following? ■ 1. Deep kneading of superfi cial muscles. ■ 2. Secure grasping of muscular tissues. ■ 3. Light stroking of the skin surface. ■ 4. Prolonged pressure on specific sites.

17. 3. Light stroking of the skin, or effl eurage, is commonly used with the Lamaze method of child- birth preparation. Light abdominal massage with just enough pressure to avoid tickling is thought to displace the pain sensation during a contraction. Deep kneading and secure grasping are typically associated with relaxation massages to relieve stress. Prolonged pressure on specifi c sites is associated with acupressure. CN: Health promotion and maintenance; CL: Apply

17. A couple visiting the infertility clinic for the fi rst time states that they have been trying to con- ceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit? ■ 1. Choose an appropriate infertility treatment method. ■ 2. Acknowledge that only 50% of infertile couples achieve a pregnancy. ■ 3. Discuss alternative methods of having a fam- ily, such as adoption. ■ 4. Describe each of the potential causes and pos- sible treatment modalities.

17. 4. By the end of the fi rst visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evalua- tion shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be diffi cult, painful, or risky. The fi rst visit is not the appropri- ate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infer- tility, a crisis for most couples. Although the couple may be in a hurry for defi nitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treat- ment, but insuffi cient data are available to suggest that a specifi c treatment modality may not be suc- cessful. Suggesting that the couple consider adop- tion at this time may inappropriately imply that the couple has no other choice. If a specifi c therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evalua- tion, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility. CN: Health promotion and maintenance; CL: Analyze

18. A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following? ■ 1. Ruptured membranes. ■ 2. Multifetal gestation. ■ 3. Diabetes mellitus. ■ 4. Hypotonic labor patterns.

18. 1. Some physicians do not allow clients with ruptured membranes to use a hot tub or jet hydro- therapy tub during labor for fear of infections. The temperature of the water should be between 98° and 100° F (36.7° to 37.8° C) to prevent hyperthermia. Jet hydrotherapy is not contraindicated for clients with multifetal gestation, diabetes mellitus, or hypotonic labor patterns. CN: Reduction of risk potential; CL: Synthesize

18. Approximately 90 minutes after birth, the nurse should encourage the mother of a term neo- nate to do which of the following? ■ 1. Feed the neonate. ■ 2. Allow the neonate to sleep. ■ 3. Get to know the neonate. ■ 4. Change the neonate's diaper.

18. 2. As part of the neonate's physiologic adap- tation to birth, at 90 minutes after birth the neonate typically is in the rest or sleep phase. During this time, the heart and respiratory rates slow and the neonate sleeps, unresponsive to stimuli. At this time, the mother should rest and allow the neonate to sleep. Feedings should be given during the fi rst period of reactivity, considered the fi rst 30 minutes after birth. During this period, the neonate's respira- tions and heart rate are elevated. Getting to know the neonate typically occurs within the fi rst hour after birth and then when the neonate is awake and during feedings. Changing the neonate's diaper can occur at any time, but at 90 minutes after birth the neonate is usually in a deep sleep, unresponsive, and probably hasn't passed any meconium. CN: Health promotion and maintenance; CL: Apply

18. A 28-year-old multigravida at 37 weeks' gestation arrives at the emergency department with a blood pressure of 160/104 mm Hg and +3 refl exes without clonus. The client is diagnosed with severe preeclampsia. The nurse collaborates with the health care provider to develop a plan of care that care will fi rst include: ■ 1. Administration of glucocorticoids (Betame- thasone). ■ 2. Vaginal or cesarean delivery of the fetus. ■ 3. Prevention of seizures with phenytoin (Dilantin). ■ 4. Reduction of fl uid retention with thiazides.

18. 2. The only known cure for severe preec- lampsia is delivery of the fetus. In severe cases, labor induction is initiated or a cesarean section is performed. Early diagnosis and careful management are used to control the disease. Medical treatment for severe preeclampsia includes bed rest in a quiet, darkened room, a regular diet, restoration of fl uid and electrolyte balance, sedation and antihyper- tensive medications, usually magnesium sulfate. Glucocorticoids such as betamethasone are used to enhance fetal lung maturity and are administered at 35 weeks' gestation or less. Glucocorticoids would not be indicated with this client who is 37 weeks' gestation. Phenytoin (Dilantin) may be used to control seizures in preclampsia but is not a fi rst line drug and does not reduce the blood pressure as- sociated with preeclampsia. During pregnancy, the drug is usually not prescribed because of the risk for fetal malformations. Although reduction of fl uid retention may make the client more comfortable, thiazide diuretics can result in serious sodium and potassium depletion, hemorrhagic pancreatitis, and neonatal thrombocytopenia. CN: Reduction of risk potential; CL: Create

18. A client is scheduled to have in vitro fertil- ization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure? ■ 1. "IVF requires supplemental estrogen to enhance the implantation process." ■ 2. "The pregnancy rate with IVF is higher than that with gamete intrafallopian transfer." ■ 3. "IVF involves bypassing the blocked or absent fallopian tubes." ■ 4. "Both ova and sperm are instilled into the open end of a fallopian tube."

18. 3. The client's understanding of the procedure is demonstrated by the statement describing IVF as a technique that involves bypassing the blocked or absent fallopian tubes. The physician removes the ova by laparoscope- or ultrasound-guided transvagi- nal retrieval and mixes them with prepared sperm from the woman's partner or a donor. Two days later, up to four embryos are returned to the uterus to increase the likelihood of a successful pregnancy. Supplemental progesterone, not estrogen, is given to enhance the implantation process. Gamete intrafal- lopian transfer (GIFT) and tubal embryo transfer have a higher pregnancy rate than IVF. However, these procedures cannot be used for clients who have blocked or absent fallopian tubes because the fertilized ova are placed into the fallopian tubes, subsequently entering the uterus naturally for implantation. In IVF, fertilization of the ova by the sperm occurs outside the client's body. In GIFT, both ova and sperm are implanted into the fallopian tubes and allowed to fertilize within the woman's body. CN: Reduction of risk potential; CL: Evaluate

18. While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following? ■ 1. Effects of the anesthetic during labor. ■ 2. Hemorrhage during the delivery process. ■ 3. Effects of analgesics used during labor. ■ 4. Decreased blood volume in the vascular system.

18. 4. The client's dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after delivery. The client is experienc- ing dizziness because not enough blood volume is available to perfuse the brain. The nurse should fi rst allow the client to "dangle" on the side of the bed for a few minutes before attempting to ambulate. By 6 hours postpartum, the effects of the anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1 to 2 hours post- partum, and the effects of local anesthesia usually disappear by 1 hour. The client scenario provides no information to indicate that the client experienced any postpartum hemorrhage. Normal blood loss dur- ing delivery should not exceed 500 mL. CN: Health promotion and maintenance; CL: Apply

Physical Assessment of the Neonatal Client 19. The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn? (pic)

19. 1. When assessing the incurving of the trunk tests for automatic refl exes in the newborn, the nurse places the infant horizontally and in a prone position with one hand, and strokes the side of the newborn's trunk from the shoulder to the buttocks using the other hand. If the reflex is present, the newborn's trunk curves toward the stimulated side. Answer 2 shows a figure for testing for a stepping response. Answer 3 shows a figure for testing for a tonic neck reflex. Answer 4 shows a figure for testing for the Moro (startle) reflex. CN: Physiological adaptation; CL: Apply

23. A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result? ■ 1. Bradycardia. ■ 2. Rapid eye movement. ■ 3. Seizures. ■ 4. Tachycardia.

23. 1. As a result of vigorous suctioning the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia. CN: Reduction of risk potential; CL: Analyze

19. A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fi brosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fi brosis is: ■ 1. X-linked recessive and the disease will only occur if the baby is a boy. ■ 2. X-linked dominant and there is no likelihood of the baby having cystic fi brosis. ■ 3. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. ■ 4. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.

19. 3. Cystic fi brosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemo- philia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typi- cally manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophos- phatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typi- cally, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene. CN: Health promotion and maintenance; CL: Apply

19. The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks very little English and delivered a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following? ■ 1. Tomatoes. ■ 2. Potatoes. ■ 3. Corn products. ■ 4. Meat products.

19. 4. Because the diet of Hispanic Americans from Mexico and Central America commonly includes beans, corn products, tomatoes, chili pep- pers, potatoes, milk, cheeses, and eggs, the nurse needs to encourage an intake of meats, dark green leafy vegetables, and other high-protein products that are rich in iron. Doing so helps to compensate for the signifi cant blood loss and subsequent iron loss that occurs during the postpartum period. Addi- tionally, fresh fruits, meats, and green leafy vegeta- bles may be scarce, possibly resulting in defi ciencies of vitamin A, vitamin D, and iron. Tomatoes are high in vitamin C, potatoes are good sources of carbohy- drates and vitamin C, and corn products are high in thiamine, but these are not rich sources of iron. CN: Health promotion and maintenance; CL: Create

19. A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal delivery. Which of the following responses would be most helpful? ■ 1. "Today's modern technology has resulted in a low maternal mortality rate." ■ 2. "Don't concern yourself with things that hap- pened in the past." ■ 3. "In the United States, mothers seldom die in childbirth." ■ 4. "What is it that concerns you about preg- nancy, labor, and delivery?"

19. 4. The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Ask- ing the client about these concerns would be most helpful to determine the client's knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconcep- tions. Although the maternal mortality rate is low in the United States, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring the client's need for a discussion about complications of pregnancy may further increase the client's anxiety. CN: Health promotion and maintenance; CL: Apply

19. Which of the following would the nurse identify as the priority to achieve when develop- ing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate? ■ 1. Decreased generalized edema within 8 hours. ■ 2. Decreased urinary output during the fi rst 24 hours. ■ 3. Sedation and decreased refl ex excitability within 48 hours. ■ 4. Absence of any seizure activity during the fi rst 48 hours.

19. 4. The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to deliver the in- fant safely. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney dam- age, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased refl ex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours. CN: Physiological adaptation; CL: Create

2. The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the fi rst stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals? ■ 1. Every 15 minutes during the latent phase. ■ 2. Every 30 minutes during the active phase. ■ 3. Every 60 minutes during the initial phase. ■ 4. Every 2 hours during the transition phase.

2. 2. Labor is categorized into three phases: latent, active, and transition. During the active stage of labor, intermittent fetal monitoring is performed every 30 minutes to detect changes in fetal heart rate such as bradycardia, tachycardia, or decelerations. If complications develop, more frequent or continuous electronic fetal monitoring may be needed. During the latent phase, intermittent monitoring is usually per- formed every 2 hours because contractions during this time are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 to 15 minutes because the client is getting closer to delivery of the baby. There is no initial phase of labor. CN: Reduction of risk potential; CL: Analyze

test 2

Complications of Pregnancy

2. A neonate is delivered by primary cesarean section at 36 weeks' gestation. The temperature in the delivery room is 70° F. To prevent heat loss from convection, which action should the nurse take? ■ 1. Dry the neonate quickly after delivery. ■ 2. Keep the neonate away from air conditioning vents. ■ 3. Place the neonate away from outside win- dows. ■ 4. Prewarm the bed.

2. 2. The neonate should be kept away from drafts, such as from air conditioning vents, which may cause heat loss by convection. Evaporation is one of the most common mechanisms by which the neonate will lose heat, such as when the moisture on the newly delivered neonate's body is converted to vapor. Radiation is heat loss between solid objects that are not in contact with one another such as walls and windows. Conduction is when heat is transferred between solid objects in contact with one another, such as when a neonate comes in con- tact with a cold mattress or scale. CN: Reduction of risk potential; CL: Synthesize

2. A client is in the first hour of her recovery after a vaginal delivery. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their base- line. Based on this information, the nurse would implement which of the following actions? ■ 1. Increase the I.V. rate. ■ 2. Recheck the admission hematocrit and hemo- globin levels. ■ 3. Report the findings to the health care provider. ■ 4. Document the findings as normal.

2. 3. At any point in the postpartum period, the lochia should be dark in color, rather than bright red. The volume should not be great enough to trickle or run from the vagina. The information provided states the fundus is fi rm, midline, and at the umbilicus, which are the expected outcomes at this point postpartum. These fi ndings would indi- cate to the nurse that the bleeding is not coming from the uterus or from uterine atony. The bladder is not palpable, which indicates the that the bleed- ing is not related to a full bladder, which is further validated by the fundus being at the umbilicus. The most likely etiology is cervical or vaginal lacerations or tears. The nurse is unable to do anything to stop this type of bleeding and must notify the health care provider. Increasing the I.V. rate will not decrease the amount or type of vaginal bleeding. Rechecking the hematocrit and hemoglobin will only provide background information for the nurse and identify the beginning levels for this mother, rather than where she is now. It will do nothing to stop the bleeding. The bleeding level and color is not nor- mal and documenting such fi ndings as normal is incorrect. CN: Management of care; CL: Synthesize

2. An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the avail- able choices, which of the following factors has the greatest impact on her birth control options? ■ 1. Satisfaction with prior methods. ■ 2. Preference of sexual partner. ■ 3. Breast- or bottle-feeding plan. ■ 4. History of clotting disease.

2. 3. Birth control plans are influenced primarily by whether the mother is breast- or bottle-feeding her infant. The maternal milk supply must be well established prior to the initiation of most hormonal birth control methods. Low dose oral contraceptives would be the exception. Use of estrogen/progesterone based pills and progesterone only pills are commonly initiated from 4 to 6 weeks postpartum because the milk supply is well established by this time. Prior experiences with birth control methods have an impact on the method chosen as does the preferences of the client's partner; however, they are not the most influential factors. A history of blood clots or thrombophlebitis is the second most important factor as several methods will be eliminated because of their potential to place the client at risk for clotting disorders. CN: Pharmacological and parenteral therapies; CL: Analysis

2. A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gesta- tion. She has had a prior pregnancy with pregnancy- induced hypertension. The assessments during this visit include BP 140/90, P 80, and + 2 edema of the ankles and feet. Based on the client's past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic? ■ 1. Headaches. ■ 2. Blood glucose level. ■ 3. Proteinuria. ■ 4. Edema in lower extremities.

2. 3. The two major defi ning characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hyper- tension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hyper- tension. The edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. The preeclamptic client will have signifi cant edema in the face and hands. Headaches are signifi cant in pregnancy- induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis. CN: Physiological adaptation; CL: Analysis

20. The nurse is administering intravenous magnesium sulfate as ordered for a client at 34 weeks' gestation with severe preeclampsia. Which of the following are desired outcomes of this therapy? Select all that apply. ■ 1. T 98, P 72, R 14. ■ 2. Urinary output <30 mL/hr. ■ 3. HR 120 BPM. ■ 4. Fetal heart rate with late decelerations. ■ 5. BP of <140/90. ■ 6. DTR's 2+. ■ 7. Magnesium level= 5.6 mg/dL. ■ 8. Clonus = 2+.

20. 1, 3, 5, 6, 7. The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromus- cular transmissions and decreasing the amount of acetylcholine liberated. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (RPM). Rates at 12 RPM or lower are associated with respiratory depression and are seen with magne- sium toxicity. Renal compromise is identifi ed with a urinary output of <30 mL per hour. A fetal heart rate that is maintained within the 112-160 range is desired without later or variable decelerations. Deep tendon refl exes that are not diminished or exaggerated are a desired outcome. The therapeu- tic magnesium sulfate level of 5-8 mg/dL is to be maintained. Clonus and hyper-refl exivity are not desired outcomes. CN: Pharmacological and parenteral therapies; CL: Evaluate

20. A full-term neonate is admitted to the normal newborn nursery. The nurse notes a Moro refl ex. What should the nurse do next? ■ 1. Call a code. ■ 2. Identify this refl ex as a normal fi nding. ■ 3. Place the neonate on seizure precautions. ■ 4. Start supplemental oxygen.

20. 2. The Moro refl ex is a normal refl ex of a neo- nate and requires no intervention. Calling a code, placing the neonate on seizure precautions, and starting supplemental oxygen are not necessary for a normally occurring refl ex. CN: Basic care and comfort; CL: Synthesize

20. A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan? ■ 1. About midway through the menstrual cycle, cervical mucus is thick and sticky. ■ 2. During ovulation, the cervix remains dry without any mucus production. ■ 3. As ovulation approaches, cervical mucus is abundant and clear. ■ 4. Cervical mucus disappears immediately after ovulation, resuming with menses.

20. 3. As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (plus or minus 2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovula- tion, the cervical mucus is thick and sticky, making it diffi cult for sperm to pass. Changes in the cervical mucus are related to the infl uences of estrogen and progesterone. Cervical mucus is always present. CN: Health promotion and maintenance; CL: Create

20. Three hours postpartum, a primiparous client's fundus is fi rm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which of the following conditions should the nurse assess further? ■ 1. Retained placental tissue. ■ 2. Uterine inversion. ■ 3. Bladder distention. ■ 4. Perineal lacerations.

20. 4. A small, constant trickle of blood and a fi rm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained pla- cental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspec- tion. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline. CN: Reduction of risk potential; CL: Analyze

20. The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity? ■ 1. Amount of bilirubin present. ■ 2. Presence of red blood cells. ■ 3. Barr body determination. ■ 4. Lecithin-sphingomyelin (L/S ratio).

20. 4. To determine fetal lung maturity, the sample of amniotic fl uid will be tested for the L/S ratio. When fetal lungs are mature, the ratio should be 2:1. Bilirubin indicates hemolysis and, if pres- ent in the fl uid, suggests Rh disease. Red blood cells should not appear in the amniotic fl uid because their presence suggests fetal bleeding. Barr body determination is a chromosome analysis of the sex chromosomes that is sometimes used when a child is born with ambiguous genitalia. CN: Health promotion and maintenance; CL: Analyze

21. Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the physician orders a continuous intravenous infu- sion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment fi ndings should the nurse report immediately? ■ 1. Respiratory rate of 12 breaths/minute. ■ 2. Patellar refl ex of +2. ■ 3. Blood pressure of 160/88 mm Hg. ■ 4. Urinary output exceeding intake.

21. 1. A respiratory rate of 12 breaths/minute suggests potential respiratory depression, an adverse effect of magnesium sulfate therapy. The medication must be stopped and the physician should be noti- fi ed immediately. A patellar refl ex of +2 is normal. Absence of a patellar refl ex suggests magnesium toxicity. A blood pressure reading of 160/88 mm Hg would be a common fi nding in a client with severe preeclampsia. Urinary output exceeding intake is not likely in a client receiving intravenous magne- sium sulfate. Oliguria is more common. CN: Pharmacological and parenteral therapies; CL: Synthesize

21. When instructing a client about the proper use of condoms for pregnancy prevention, which of the following instructions would be included to ensure maximum effectiveness? ■ 1. Place the condom over the erect penis before coitus. ■ 2. Withdraw the condom after coitus when the penis is fl accid. ■ 3. Ensure that the condom is pulled tightly over the penis before coitus. ■ 4. Obtain a prescription for a condom with non- oxynol 9.

21. 1. To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples fi nd condom use objectionable because foreplay may have to be inter- rupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes fl accid. Otherwise sperm may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescrip- tion for a condom with nonoxynol 9 because these are sold over the counter. CN: Reduction of risk potential; CL: Apply

21. Assessment of a 15-year-old primigravid client at term in active labor reveals cervical dilation at 7 cm with complete effacement. The nurse should assess the client for which of the following fi rst? ■ 1. Uterine inversion. ■ 2. Cephalopelvic disproportion (CPD). ■ 3. Rapid third stage of labor. ■ 4. Decreased ability to push.

21. 2. Adolescent pregnancy carries an increased risk of pregnancy-induced hypertension, iron-defi - ciency anemia, and CPD. CPD is a concern because maturation of the skeletal bones (including the pelvis) is commonly not complete in adolescents. Adolescent labor does not differ from labor in the older woman if no CPD is present. A prolonged fi rst stage of labor and poor fetal descent may indicate that CPD exists. Uterine inversion, a rapid third stage of labor, or decreased ability to push may occur regardless of the client's age. CN: Reduction of risk potential; CL: Analyze

21. After the delivery of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying the neonate, what should the nurse do next? ■ 1. Assign the fi rst Apgar score. ■ 2. Place the head in a "sniff" position. ■ 3. Administer oxygen. ■ 4. Start cardiac compressions.

21. 2. When resuscitating the neonate, the principle of airway-breathing-circulation (ABCs) must be followed. Positioning the neonate on the back with the neck slightly extended in the "sniffing" position will open the airway, allowing oxygen to get to the neonate's lungs. Apgar scores are an evaluation of the neonate's status at 1 and 5 minutes of life. Waiting to open the airway until after assigning an Apgar score would be a waste of valuable time. If the airway is not patent, oxygen cannot be delivered. Cardiac compres- sion must be accompanied by adequate oxygenation. CN: Physiological adaptation; CL: Synthesize

21. At a postpartum check up 11 days after delivery, the nurse asks the client about the color of her lochia. Which of the following colors is expected? ■ 1. Dark red. ■ 2. Pink. ■ 3. Brown. ■ 4. White.

21. 4. On about the eleventh postpartum day, the lochia should be lochia alba, clear or white in color. Lochia rubra, which is dark red to red, may persist for the fi rst 2 to 3 days postpartum. From day 3 to about day 10, lochia serosa, which is pink or brown, is normal. CN: Health promotion and maintenance; CL: Evaluate

22. After instructing a primiparous client about episiotomy care, which of the following client state- ments indicates successful teaching? ■ 1. "I'll use hot, sudsy water to clean the epi- siotomy area." ■ 2. "I wipe the area from front to back using a blotting motion." ■ 3. "Before bedtime, I'll use a cold water sitz bath." ■ 4. "I can use ice packs for 3 to 4 days after delivery."

22. 2. The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client's discomfort and may even burn the client in a very tender area. After the fi rst 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the fi rst 24 hours. CN: Health promotion and maintenance; CL: Evaluate

22. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do fi rst? ■ 1. Insert an airway to improve oxygenation. ■ 2. Note the time when the seizure begins and ends. ■ 3. Call for immediate assistance. ■ 4. Turn the client to her left side.

22. 3. If a client begins to have a seizure, the fi rst action by the nurse is to remain with the client and call for immediate assistance. The nurse needs to have some assistance in managing this client. After the seizure, the client needs intensive monitoring. An airway can be inserted, if appropriate, after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side should be done after assistance is obtained. CN: Reduction of risk potential; CL: Synthesize

22. A 19-year-old primigravid client at 38 weeks' gestation is admitted to the hospital in active labor that began 8 hours ago. When the client's cervix is 7 cm dilated and the presenting part is at +1 station, the client tells the nurse, "I need to push!" Which of the following would the nurse do next? ■ 1. Use the McDonald procedure to widen the pelvic opening. ■ 2. Increase the rate of oxygen and intravenous fl uids. ■ 3. Instruct the client to use a pant-blow pattern of breathing. ■ 4. Tell the client to push only when absolutely necessary.

22. 3. Pushing during the fi rst stage of labor, when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more diffi cult. The client should be encour- aged to use a pant-blow (or blow-blow) pattern of breathing to help overcome the urge to push. The McDonald procedure is used for cervical cerclage for an incompetent cervix and is inappropriate here. Increasing the rate of oxygen and intravenous fl uids will not alleviate the pressure that the client is feel- ing. The client should not push even if she feels the urge to do so because this may result in cervical edema at 7 cm dilation. CN: Health promotion and maintenance; CL: Synthesize

22. A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neo- nate has the following signs: heart rate 110, inter- mittent grunting with respiratory rate of 70, fl accid tone, no response to stimulus, overall pale white in color. The Apgar score is: ■ 1. 2. ■ 2. 3. ■ 3. 4. ■ 4. 6.

22. 3. The neonate has a heart rate greater than 100, which earns him 2 points. His respiratory rate of 70 is equivalent to a 2 on the scale. His fl accid muscle tone is equal to 0 on the scale. The lack of response to stimulus also equals 0, as does his overall pale white color. Thus, the total score equals 4. CN: Basic care and comfort; CL: Apply

22. A multigravid client will be using medroxy- progesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the cli- ent about this method, which of the following client statements indicates effective teaching? ■ 1. "This method of family planning requires monthly injections." ■ 2. "I should have my fi rst injection during my menstrual cycle." ■ 3. "One possible adverse effect is absence of a menstrual period." ■ 4. "This drug will be given by subcutaneous injections."

22. 3. With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are com- mon adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramus- cular injections every 3 months. The fi rst injection should occur within 5 days after menses. CN: Reduction of risk potential; CL: Evaluate

23. After explaining the procedure for using a portable sitz bath to a primiparous client who deliv- ered 30 hours ago, which of the following would the nurse do next? ■ 1. Fill the collecting bag with water at a tem- perature of 107° F (41.25° C). ■ 2. Spray the perineal area with the ordered anal- gesic spray. ■ 3. Wash hands and don clean gloves for the procedure. ■ 4. Assess the client's perineum for swelling and redness.

23. 3. After explaining the procedure to the client, the nurse should wash hands and don clean gloves for the procedure. Washing the hands prevents the spread of infection. Standard precau- tions are necessary to protect both the client and the nurse. The temperature of the water should be between 100° and 105° F (37.4° and 40° C) to prevent burns. Spraying the perineal area with the ordered analgesic spray is done after the sitz bath to provide the greatest pain relief. Assessing the client's perineum for swelling and redness is part of the nursing assessment and needs to be done after hand washing and donning clean gloves. Also, the assessment would be done before the nurse explains the procedure. CN: Safety and infection control; CL: Synthesize

23. Which of the following instructions should the nurse include in the teaching plan for a 30-year- old multiparous client who will be using an intra- uterine device (IUD) for family planning? ■ 1. Amenorrhea is a common adverse effect of IUDs. ■ 2. The client needs to use additional protection for conception. ■ 3. IUDs are more costly than other forms of con- traception. ■ 4. Severe cramping may occur when the IUD is inserted.

23. 4. Severe cramping and pain may occur as the device is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses, because it is unlikely that she is pregnant at that time. Com- mon adverse effects of IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea. Uterine infection or ectopic pregnancy may occur. The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are less costly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use. CN: Reduction of risk potential; CL: Apply

23. Which of the following would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia? ■ 1. Giving frequent sips of water. ■ 2. Applying extra blankets for warmth. ■ 3. Providing frequent perineal cleansing. ■ 4. Offering encouragement and support.

23. 4. The client is in the transition phase of the fi rst stage of labor. During this phase, the client needs encouragement and support because this is a diffi cult and painful time, when contractions are especially strong. Usually, the client fi nds it diffi - cult to maintain self control. Everything else seems secondary to her as she progresses into the second stage of labor and delivery. Although ice chips may be given, typically the client does not desire sips of water. Labor is hard work. Generally, the client is perspiring and does not desire additional warmth. Frequent perineal cleansing is not necessary unless there is excessive amniotic fl uid leaking. CN: Health promotion and maintenance; CL: Synthesize

24. After counseling a 35-year-old client about breast self-examination and mammography, the nurse determines that the client has understood the instructions when the client states which of the fol- lowing? ■ 1. "I should have a mammogram every year once I'm 40." ■ 2. "I should schedule a mammography examina- tion during my menstrual period." ■ 3. "Mammography screening is inexpensive." ■ 4. "Mammography is an extremely painful procedure."

24. 1. The American Cancer Society recommends an annual mammography screening examination for all women after the age of 40. Some high-risk women may begin annual screening at an earlier age. Some women have never had a mammogram because of fear or misconceptions. Mammography should be scheduled after the client's menses to reduce complaints of breast tenderness. Mammog- raphy screening is considered expensive, especially by low-income women. Although some discomfort is common because the breast is placed between two plates during the screening process, the procedure should not be considered extremely painful. CN: Health promotion and maintenance; CL: Evaluate

24. To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures? ■ 1. Sagittal. ■ 2. Lambdoidal. ■ 3. Coronal. ■ 4. Frontal.

24. 1. The sagittal suture is the most readily felt during a vaginal examination. When the fetus is in the LOA position, the occiput faces the mother's left. The lambdoid suture is on the side of the skull. The coronal suture is a horizontal suture across the front portion of the fetal skull that forms the anterior fontanel. It may be felt with a brow presentation. The frontal suture may be felt with a brow or face presentation. CN: Health promotion and maintenance; CL: Apply

24. When reviewing the prenatal history for a newly delivered neonate, the nurse notes that the mother has neurofi bromatosis. The nurse should further assess the neonate for: ■ 1. Acrocyanosis. ■ 2. Café au lait spots. ■ 3. Port wine nevus. ■ 4. Strawberry hemangiomas.

24. 2. There is a correlation between café au lait spots and the development of neurofi bromatosis. Acrocyanosis is a normal fi nding of bluish hands and feet as a result of poor capillary perfusion. Port wine nevus and strawberry hemangiomas are a col- lection of dilated capillaries and are not associated with any other disease process. CN: Reduction of risk potential; CL: Analyze

24. A primiparous client, 20 hours after delivery, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse's instructions? ■ 1. Start in a sitting position, then lie back, and return to a sitting position, repeating this fi ve times. ■ 2. Assume a prone position, then do push-ups by using the arms to lift the upper body. ■ 3. Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles. ■ 4. Flex the knees while supine, then bring chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling.

24. 3. After an uncomplicated delivery, postpar- tum exercises may begin on the fi rst postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees fl exed, inhaling deeply while allowing the abdo- men to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reach- ing for the knees are ordinarily too strenuous for the fi rst postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks. CN: Health promotion and maintenance; CL: Apply

24. A primigravid client with severe preeclamp- sia exhibits hyperactive, very brisk patellar refl exes with two beats of ankle clonus present. The nurse documents the patellar refl exes as which of the following? ■ 1. 1+. ■ 2. 2+. ■ 3. 3+. ■ 4. 4+.

24. 4. These fi ndings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements. CN: Physiological adaptation; CL: Apply

25. A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the physician with a lumbar puncture on this neonate. What should the nurse do to assist in this proce- dure? Select all that apply. ■ 1. Administer the I.V. antibiotic. ■ 2. Hold the neonate steady in the correct position. ■ 3. Ensure a patent airway. ■ 4. Maintain a sterile fi eld. ■ 5. Obtain a serum glucose level.

25. 2, 3, 4. Holding the neonate steady and in the proper position will help ensure a safe and accurate lumbar puncture. The neonate is usually held in a "C" position to open the spaces between the vertebral column. This position puts the neo- nate at risk for airway obstruction. Thus, ensuring the patency of the airway is the fi rst priority, and the nurse should observe the neonate for adequate ventilation. Maintaining a sterile fi eld is important to avoid infection in the neonate. It is not necessary to administer antibiotics or obtain a serum glucose level during the procedure. CN: Safety and infection control; CL: Synthesize

25. A multiparous client whose fundus is fi rm and midline at the umbilicus 8 hours after a vagi- nal delivery tells the nurse that when she ambu- lated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explain- ing to the client about the increased lochia on ambulation? ■ 1. Her bleeding needs to be reported to the phy- sician immediately. ■ 2. The increased lochia occurs from lochia pool- ing in the vaginal vault. ■ 3. The increase in lochia may be an early sign of postpartum hemorrhage. ■ 4. This increase in lochia usually indicates retained placental fragments.

25. 2. Lochia can be expected to increase when the client fi rst ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and fl ows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notifi ed. Early postpartum hemorrhage occurs during the fi rst 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is fi rm and midline. Late postpartal hemorrhage, occurring after the fi rst 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site. CN: Health promotion and maintenance; CL: Synthesize

25. After a lengthy labor process, a primigravid client delivers a healthy newborn boy with a moder- ate amount of skull molding. Which of the following would the nurse include when explaining to the parents about this condition? ■ 1. It is typically seen with breech deliveries. ■ 2. It usually lasts a day or two before resolving. ■ 3. It is unusual when the brow is the presenting part. ■ 4. Surgical intervention may be necessary to alleviate pressure.

25. 2. Molding occurs with vaginal deliveries and is commonly seen in newborns. This is espe- cially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presenta- tion. Surgical intervention is not necessary. CN: Health promotion and maintenance; CL: Create

25. A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. Her mother is at the bed- side. The client's blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure? ■ 1. Decreased contraction intensity. ■ 2. Decreased temperature. ■ 3. Epigastric pain. ■ 4. Hyporefl exia.

25. 3. Epigastric pain or acute right upper quad- rant pain is associated with the development of eclampsia and an impending seizure; this is thought to be related to liver ischemia. Decreased contrac- tion intensity is unrelated to the severity of the preeclampsia. Typically, the client's temperature increases because of increased cerebral pressure. A decrease in temperature is unrelated to an im- pending seizure. Hyporefl exia is not associated with an impending seizure. Typically, the client would exhibit hyperrefl exia. CN: Physiological adaptation; CL: Analyze

25. After instructing a 40-year-old woman about osteoporosis after menopause, the nurse determines that the client needs further instruction when the client states which of the following? ■ 1. "One cup of yogurt is the equivalent of one glass of milk." ■ 2. "Women who do not eat dairy products should consider calcium supplements." ■ 3. "African American women are at the greatest risk for osteoporosis." ■ 4. "Estrogen therapy at menopause can reduce the risk of osteoporosis."

25. 3. Small-boned, fair-skinned women of northern European descent are at the greatest risk for osteoporosis, not African American women. One cup of yogurt or 1.5 oz of hard cheese is the equivalent of one glass of milk. Women who do not eat dairy products, such as women who are lactose intoler- ant, should consider using calcium supplements. Inadequate lifetime intake of calcium is a major risk factor for osteoporosis. Estrogen therapy, or some of the newer medications that are not estrogen based, can greatly reduce the incidence of osteoporosis. CN: Reduction of risk potential; CL: Evaluate

26. A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confi rm this diagnosis? Select all that apply. ■ 1. Hypotension. ■ 2. Gush of blood from the vagina. ■ 3. Intense, severe, tearing type of abdominal pain. ■ 4. Uterus is hard and in a constant state of con- traction. ■ 5. Inability to palpate the uterus. ■ 6. Diaphoresis.

26. 1, 2, 5, 6. Uterine inversion is indicated by a sudden gush of blood from the vagina leading to decreased blood pressure, and an inability to palpate the uterus since it may be in or protrud- ing from the vagina and any signs of blood loss such as diaphoresis, paleness, or dizziness could be observed at this time. Intense pain and a hard contracting uterus are not associated with uterine inversion. CN: Reduction of risk potential; CL: Analyze

26. When developing a teaching plan for an 18 year old client who asks about treatments for sexually transmitted diseases, the nurse should explain that? ■ 1. Acyclovir (Zovirax) can be used to cure her- pes genitalis. ■ 2. Chlamydia trachomatis infections are usually treated with penicillin. ■ 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections. ■ 4. Metronidazole (Flagyl) is used to treat condy- lomata acuminata.

26. 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections and is commonly combined with doxycycline hyclate (Vi- bramycin). Both the client and her partner should be treated if gonorrhea is present. Acyclovir (Zovirax) can be used to treat herpes genitalis; however, the drug does not cure the disease. Chlamydia tracho- matis infections are usually treated with antibiotics such as doxycycline or azithromycin (Zithromax). Metronidazole (Flagyl) is used to treat trichomonia- sis vaginalis, not condylomata acuminata (genital warts). CN: Pharmacological and parenteral therapies; CL: Create

26. After a vaginal delivery of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse noti- fi es the pediatrician based on the analysis that this may be indicative of ? ■ 1. Respiratory anomalies. ■ 2. Musculoskeletal anomalies. ■ 3. Cardiovascular anomalies. ■ 4. Facial anomalies.

26. 3. Normally, the umbilical cord has two umbilical arteries and one vein. When a neonate is born with only one artery and one vein, the nurse should notify the pediatrician for further evaluation of cardiac anomalies. Other common congenital problems associated with a missing artery include renal anomalies, central nervous system lesions, tracheoesophageal fi stulas, trisomy 13, and trisomy 18. Respiratory anomalies are associated with dyspnea and respiratory distress; musculoskeletal anomalies include fractures or dislocated hip; and facial anomalies are associated with fetal alcohol syndrome or Down syndrome, not a missing umbili- cal artery. CN: Reduction of risk potential; CL: Analyze

26. Fifteen minutes after a client experiences an eclamptic seizure, the nurse should assess the client for which of the following? ■ 1. Polyuria. ■ 2. Facial fl ushing. ■ 3. Hypotension. ■ 4. Uterine contractions.

26. 4. After an eclamptic seizure, the client com- monly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor, because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial fl ushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered. CN: Physiological adaptation; CL: Analyze

26. Four hours after delivering a viable neonate by spontaneous vaginal delivery under epidural anesthesia, the client states she needs to urinate. The nurse should next: ■ 1. Catheterize the client to obtain an accurate measurement. ■ 2. Palpate the bladder to determine distention. ■ 3. Assess the fundus to see if it is at the midline. ■ 4. Measure the first two voidings and record the amount.

26. 4. After delivery, the nurse should plan to measure the client's fi rst two voidings and record the amount to make sure that the client is emptying the bladder. Frequent voidings of less than 150 mL suggest that the client is experiencing urinary reten- tion. In addition, if urinary retention is occurring, the bladder may be palpable and the fundus may be displaced from midline. The client does not need to be catheterized unless there is evidence of urinary retention. Palpation of the bladder before voiding is unnecessary. However, if the client has diffi culty voiding or exhibits signs of urinary retention, then bladder palpation is indicated. The fundus can be displaced by a full bladder and should be assessed after the client voids. CN: Health promotion and maintenance; CL: Synthesize

27. A client at 36 weeks' gestation with eclamp- sia begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for: ■ 1. Abruptio placentae. ■ 2. Transverse lie. ■ 3. Placenta accreta. ■ 4. Uterine atony.

27. 1. After an eclamptic seizure, the client is at risk for abruptio placentae due to severe vasocon- striction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested by a board-like abdomen and nonreassuring fetal heart rate tracing. Transverse lie or shoulder presenta- tion, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus, placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fl uid. Placenta accreta, a rare phenomenon, refers to a condition in which the placenta abnor- mally adheres to the uterine lining. Uterine atony, or relaxed uterus, may occur after delivery, leading to postpartum hemorrhage. CN: Physiological adaptation; CL: Analyze

27. A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. After discussing the various causes of male infertility, the nurse determines that the male partner needs further instruction when he states which of the following as a cause? ■ 1. Seminal fl uid with an alkaline pH. ■ 2. Frequent exposure to heat sources. ■ 3. Abnormal hormonal stimulation. ■ 4. Immunologic factors.

27. 1. The client needs further instruction when he says that one cause of male infertility is decreased sperm count due to seminal fl uid that has an alkaline pH. A slightly alkaline pH is neces- sary to protect the sperm from the acidic secretions of the vagina and is a normal fi nding. An alkaline pH is not associated with decreased sperm count. However, seminal fl uid that is abnormal in amount, consistency, or chemical composition suggests obstruction, infl ammation, or infection, which can decrease sperm production. The typical number of sperm produced during ejaculation is 400 million. Frequent exposure to heat sources, such as saunas and hot tubs, can decrease sperm production, as can abnormal hormonal stimulation. Immunologic factors produced by the man against his own sperm (autoantibodies) or by the woman can cause the sperm to clump or be unable to penetrate the ovum, thus contributing to infertility. CN: Health promotion and maintenance; CL: Evaluate

27. After delivery of a viable neonate, a 20-year- old primiparous client comments to her mother and the nurse about the baby. Which of the following comments would the nurse interpret as a possible sign of potential maternal-infant bonding problems? ■ 1. "He's got my funny-looking ears!" ■ 2. "I think my mother should give him the fi rst feeding." ■ 3. "He's a lot bigger than I expected him to be." ■ 4. "I want to buy him a blue outfi t to wear when we get home."

27. 2. Avoidance, hostility, or low-key (passive) behavior toward the baby may be a cue to potential bonding problems. The nurse should encourage the client to give the baby the fi rst feeding to begin the bonding process. Expressions of disappointment with the baby's gender may also signal problems with maternal-infant bonding. Comparing the baby's fea- tures to her own indicates identifi cation of the neonate as belonging to her, suggesting bonding with neonate. Comparing the actual neonate with the "fantasized neonate" is a normal maternal reaction. Wanting to buy a blue outfi t indicates an interest in and connec- tion with the neonate and is a sign of bonding. CN: Reduction of risk potential; CL: Analyze

27. A primiparous client who delivered vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following? ■ 1. Fatigue. ■ 2. Fainting. ■ 3. Diuresis. ■ 4. Hygiene needs.

27. 2. Clients sometimes feel faint or dizzy when taking a shower for the fi rst time after delivery because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her fi rst shower after delivery. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is com- mon and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower. CN: Safety and infection control; CL: Analyze

27. Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to fi nd about the head circumference? ■ 1. Equal to the chest circumference. ■ 2. Approximately 2 cm larger than the chest. ■ 3. About 3 cm smaller than the chest. ■ 4. Approximately 4 cm larger than the chest.

27. 2. Normally at birth, the neonate's head circumference is approximately 2 cm larger than the chest circumference. The average normal head circumference is 13 to 14 inches (33 to 35 cm); average normal chest circumference is 12.5 to 14 inches (31 to 35 cm). A head circumference that is equal to or smaller than the chest circum- ference may indicate microcephaly; a head that is larger than normal may indicate hydrocephalus. The presence of any of these conditions warrants further evaluation. CN: Health promotion and maintenance; CL: Analyze

28. A 24-year-old woman is being assessed for a malformation of the uterus. The figure below indicates which of the following uterine malformations? PIC ■ 1. Septate uterus. ■ 2. Bicornate uterus. ■ 3. Double uterus. ■ 4. Uterus didelphys.

28. 2. A bicornate uterus has a "Y" shape and appears to be a double uterus but in fact has only one cervix. A septate uterus contains a septum that extends from the fundus to the cervix, thus divid- ing the uterus into two separate compartments. A double uterus has two uteri, each of which has a cervix. A uterus didelphys occurs when both uteri of a double uterus are fully formed. CN: Physiological adaptation; CL: Apply

28. The nurse is reviewing the chart of a multi- gravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results? ■ 1. Platelets 200,000 mm3. ■ 2. Lactate dehydrogenase (LDH) > 200 units/L. ■ 3. Uric acid 3 mg/dL. ■ 4. Aspartate aminotransferase (AST) 15 units/L.

28. 2. The normal value of an LDH in a non-preg- nant person is 45 to 90 units/L. LDH elevations in- dicate tissue destruction that can occur with HELLP syndrome. This platelet range is in the normal range of 150,000 to 400,000/mm3 and remains unchanged during pregnancy. Uric acid in a non-pregnant woman is 2 to 6.6 mg/dL. AST normal range is 4 to 20 units/L, abnormal levels indicate liver damage. CN: Reduction of risk potential; CL: Synthesize

31. While performing a complete assessment of a term neonate, which of the following fi ndings would alert the nurse to notify the pediatrician? ■ 1. Red refl ex in the eyes. ■ 2. Expiratory grunt. ■ 3. Respiratory rate of 45 breaths/minute. ■ 4. Prominent xiphoid process.

31. 2. An expiratory grunt is signifi cant and should be reported promptly, because it may indi- cate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts. The presence of a red refl ex in the eyes is normal. An absent red refl ex may indicate congenital cata- racts. A respiratory rate of 45 breaths/minute and a prominent xiphoid process are normal fi ndings in a term neonate. CN: Reduction of risk potential; CL: Synthesize

28. A primiparous client who delivered 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate? ■ 1. "Ask for some pain medication before you sit down." ■ 2. "Squeeze your buttock muscles together before sitting down." ■ 3. "Keep a relaxed posture before sitting down with your full weight." ■ 4. "Ask the physician for some analgesic cream or spray."

28. 2. The nurse should instruct the client to squeeze or contract the muscles of the buttocks together before sitting down in the chair; this contracts the pelvic fl oor muscles, which reduces the tension on the tender perineal area. Then the client should put her full weight slowly down on the chair. Pain medication may only be ordered for every 3 to 4 hours, so the client may not be able to receive pain medication every time she desires to sit in the chair. The episiotomy pain usually fades by the fi fth or sixth postpartum day. Maintaining a relaxed posture before sitting does not contract the pelvic fl oor muscles. Most physicians order an analgesic cream or spray when a client has an epi- siotomy, but they provide only temporary relief. CN: Health promotion and maintenance; CL: Synthesize

28. Assessment of a 23-year-old primigravid cli- ent at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client? ■ 1. Input from the large sensory fi bers opens the gate. ■ 2. Labor pain is a matter of individual perception. ■ 3. Slow abdominal breathing can open the gate. ■ 4. The gating mechanism is in the spinal cord.

28. 4. According to the gate-control theory of pain perception, when the endings of small periph- eral nerve fi bers detect a stimulus, they transmit it to cells in the dorsal horn of the spinal cord. These impulses pass through a network of cells in the spinal cord called the substantia gelatinosa, and a synapse occurs that returns the transmission to the peripheral site through a motor nerve. The impulse is then transmitted through the spinal cord to the brain, where the impulse is perceived as pain. Gate- control mechanisms in the spinal cord are capable of halting these impulses (closing the gate), so that pain is not perceived. Input from the large sensory fi bers closes the gate. Telling the client that labor pain is a matter of individual perception is not helpful and does not explain the gate-control theory. Deep chest breathing or other breathing techniques can help to keep the "gate" closed, not open. CN: Health promotion and maintenance; CL: Apply

82. A 24-year-old primipara who has delivered a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. When develop- ing the nutritional teaching plan for the mother about the neonate's daily calorie allotment, the nurse should determine that the number of calories required by the neonate each day per pound of body weight is which of the following? ■ 1. 30 to 35. ■ 2. 40 to 45. ■ 3. 50 to 55. ■ 4. 60 to 65.

82. 3. As a general rule, most neonates require 50 to 55 calories per pound of body weight, or about 117 calories per kilogram of weight, each day. If the neo- nate receives less than this amount, malnutrition may occur. More than this amount can lead to obesity. CN: Basic care and comfort; CL: Apply

28. After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction? ■ 1. "The molding was caused by an overlapping of the baby's cranial bones during my labor." ■ 2. "The amount of molding is related to the amount and length of pressure on the head." ■ 3. "The molding will usually disappear in a couple of days." ■ 4. "Brain damage may occur if the molding doesn't resolve quickly."

28. 4. The mother needs further instruction if she says the molding can result in brain damage. Brain damage is highly unlikely. Molding occurs during vaginal delivery when the cranial bones tend to override or overlap as the head accommodates to the size of the mother's birth canal. The amount and duration of pressure on the head infl uence the degree of molding. Molding usually disappears in a few days without any special attention. CN: Health promotion and maintenance; CL: Evaluate

29. The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience which of the following? ■ 1. No pain. ■ 2. Sharp pain. ■ 3. Light pain. ■ 4. Moderate pain.

29. 1. According to the gate-control theory of pain, a closed gate means that the client should feel no pain. The gate-control theory of pain refers to the gate-control mechanisms in the substantia gelatinosa that are capable of halting an impulse at the level of the spinal cord so the impulse is never perceived at the brain level as pain (i.e., a process similar to keeping a gate closed). CN: Health promotion and maintenance; CL: Evaluate

29. Which of the following would the nurse include in the primiparous client's discharge teach- ing plan about measures to provide visual stimula- tion for the neonate? ■ 1. Maintain eye contact while talking to the baby. ■ 2. Paint the baby's room in bright colors accented with teddy bears. ■ 3. Use brightly colored animals and cartoon fi gures on the wall. ■ 4. Move a brightly colored rattle in front of the baby's eyes.

29. 1. Neonates like to look at eyes, and eye- to-eye contact is a highly effective way to provide visual stimulation. The parent's eyes are circular, move from side to side, and become larger and smaller. Neonates have been observed to fi x on them. In general, neonates prefer circular objects of darkness against a white background. Sharp black and white images of geometric fi gures are appropri- ate. Use of bright colors on the walls and moving a colorful rattle do not provide as much visual stimu- lation as eye-to-eye contact with talking. Brightly colored animals and cartoon fi gures are more appro- priate at approximately 1 year of age. CN: Health promotion and maintenance; CL: Create

29. An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hyperten- sion. She was treated with methyldopa (Aldomet) before becoming pregnant. When counseling the cli- ent about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following? ■ 1. "I need to reduce my caloric intake to 1,200 calories a day." ■ 2. "A regular diet is recommended during preg- nancy." ■ 3. "I should eat more frequent meals if I get heartburn." ■ 4. "I need to consume more fl uids and fi ber each

29. 1. Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating more frequent, smaller meals decreases heartburn resulting from the refl ux of acidic secre- tions into the lower esophagus. Pregnant women need adequate hydration (fl uids) and fi ber to pre- vent constipation. CN: Basic care and comfort; CL: Evaluate

3. The physician orders ampicillin 100 mg/kg/ dose for a newly admitted neonate. The neonate weighs 1,350 g. How many milligrams should the nurse administer? ________________________ mg.

3. 135 mg The recommended dose of ampicillin for a neonate is 100 mg/kg/dose. First, determine the neonate's weight in kilograms, and then multiply the kilograms by 100 mg. The nurse should use this formula: 1,000 g = 1 kg 1,350 g = 1.35 kg 100 mg × 1.35 kg = 135 mg/kg CN: Pharmacological and parenteral therapies; CL: Apply

3. Assessment reveals that the fetus of a mul- tigravid client is at + 1 station and 8 cm dilated. Based on these data, the nurse should fi rst: ■ 1. Ask anesthesia to increase epidural rate. ■ 2. Assist the client to push if she feels the need to do so. ■ 3. Encourage the client to breathe through the urge to push. ■ 4. Support family members in providing comfort measures.

3. 3. The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the cli- ent to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. This may occur quickly with a multigravid client. Comfort measures are important for the client at this time, but are not the highest priority for the nurse. CN: Management of care; CL: Synthesize

3. The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concern- ing fetal movement? ■ 1. "If the fetus is becoming less active than before." ■ 2. "If it takes longer each day for the fetus to move 10 times." ■ 3. "If the fetus stops moving for 12 hours." ■ 4. "If the fetus moves more often than 3 times an hour."

3. 4. The fetus is considered well if it moves more often than 3 times in 1 hour. Daily fetal move- ment counting is part of all high-risk assessments and is a noninvasive, inexpensive method of moni- toring fetal well-being. The health care provider should be notifi ed if there is a gradual slowing over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer. CN: Reduction of risk potential; CL: Evaluation

3. After the nurse instructs a 20-year-old nul- ligravid client on how to perform a breast self- examination, which of the following client statements indicates that the teaching has been successful? ■ 1. "I should perform breast self-examination on the day my menstrual fl ow begins." ■ 2. "It's important that I perform breast self- examination on the same day each month." ■ 3. "If I notice that one of my breasts is much smaller than the other, I shouldn't worry." ■ 4. "If there is discharge from my nipples, I should call my health care provider."

3. 4. The nurse determines that the client has understood the instructions when the client says that she will notify her physician if she notices discharge or bleeding because this may be symptom- atic of underlying disease. Ideally, breast self-exam- ination should be performed about 1 week after the onset of menses because hormonal infl uences on breast tissue are at a low ebb at this time. The client should perform breast self-examination on the same day each month only if she has stopped menstruat- ing (as with menopause). The client's breasts should mirror each other. If one breast is signifi cantly larger than the other, or if there is "pitting" of breast tissue, a tumor may be present. CN: Reduction of risk potential; CL: Evaluate

3. The nurse is caring for a G 3, T 3, P 0, Ab 0, L 3 woman who is one day postpartum following a vaginal delivery. Which of the following indicates a need for further assessment? ■ 1. Increased hematocrit and hemoglobin. ■ 2. White blood cell (WBC) count of 15,000. ■ 3. Pulse of 60. ■ 4. Temperature of 100.8° F.

3. 4. Within the fi rst 24 hours postpartum, the maternal temperature may increase to 100.4°F, a normal postpartum fi nding attributed to dehydra- tion. A temperature higher than 100.4°F after the fi rst 24 hours indicates a potential for infection. Hemoconcentration is a normal fi nding postpartum due to the remobilization and rapid loss of excess body fl uids. WBC count is normally elevated as a response to the infl ammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fl uid into the vascular bed, decreased pressure from the uterus on vessels, blood fl ow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume. CN: Physiological adaptation; CL: Analyze

30. After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hyper- tension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following? ■ 1. "I may develop hyperthyroidism because of my high blood pressure." ■ 2. "I need close monitoring because I may have a small-for-gestational-age infant." ■ 3. "It's possible that I will have excess amniotic fl uid and may need a cesarean section." ■ 4. "I may develop placenta accreta, so I need to keep my clinic appointments."

30. 2. Women with chronic hypertension dur- ing pregnancy are at risk for complications such as preeclampsia (about 25%), abruptio placentae, and intrauterine growth retardation, resulting in a small-for-gestational-age infant. There is no association between chronic hypertension and hyperthyroidism. Pregnant women with chronic hypertension are not at an increased risk for hy- dramnios (polyhydramnios), an abnormally large amount of amniotic fl uid. Clients with diabetes and multiple gestations are at risk for this condition. Placenta accreta, a rare placental abnormality, refers to a condition in which the placenta abnormally ad- heres to the uterine lining. It is not associated with chronic hypertension. CN: Reduction of risk potential; CL: Evaluate

30. Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term? ■ 1. Ear lying fl at against the head. ■ 2. Absence of rugae in the scrotum. ■ 3. Sole creases covering the entire foot. ■ 4. Square window sign angle of 90 degrees.

30. 3. Sole creases covering the entire foot are indicative of a term neonate. If the neonate's ear is lying fl at against the head, the neonate is most likely preterm. An absence of rugae in the scrotum typi- cally suggests a preterm neonate. A square window sign angle of 0 degrees occurs in neonates of 40 to 42 weeks' gestation. A 90-degree square window angle suggests an immature neonate of approxi- mately 28 to 30 weeks' gestation. CN: Health promotion and maintenance; CL: Apply

30. During a visit to the prenatal clinic, a preg- nant client at 32 weeks' gestation complains of heartburn. The client needs further instruction when she says she must do what? ■ 1. Avoid highly seasoned foods. ■ 2. Avoid laying down right after eating. ■ 3. Eat small, frequent meals. ■ 4. Consume liquids only between meals.

30. 4. Consuming most liquids between meals rather than at the same time as eating is an excel- lent strategy to deter nausea and vomiting in preg- nancy but does not relieve heartburn. During the third trimester, progesterone causes relaxation of the sphincter and the pressure of the fetus against the stomach increases the potential of heartburn. Avoid- ing highly seasoned foods, remaining in an upright position after eating, and eating small, frequent meals are strategies to prevent heartburn. CN: Physiological adaptation; CL: Evaluate

30. The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess: ■ 1. Fetal heart rate variability. ■ 2. Cervical dilation again. ■ 3. Status of membranes. ■ 4. Bladder status.

30. 4. The bladder status should be monitored throughout the labor process, but especially before the client begins pushing. A full bladder can impede the progress of labor and slow fetal descent. Because she has had an epidural anesthetic, it is most likely that the client is receiving intravenous fl uids, contributing to a full bladder. The client also does not feel the urge to void because of the anesthetic. Although it is important to monitor membrane status and fetal heart rate variability throughout labor, this does not affect the client's ability to push. There is no need to recheck cervical dilation because increasing the frequency of examinations can increase the client's risk for infection. CN: Reduction of risk potential; CL: Analyze

31. For the past 8 hours, a 20-year-old primi- gravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for: ■ 1. Exhaustion. ■ 2. Chills and fever. ■ 3. Fluid overload. ■ 4. Meconium-stained fluid.

31. 1. The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client is having prolonged labor, the nurse should monitor the client for signs of exhaustion as well as dehydra- tion. Hypotonic contractions, which are painful but ineffective, may be occurring. Oxytocin augmenta- tion may be necessary. Chills and fever are manifes- tations of an infection and are not associated with a prolonged latent phase of labor. Fluid overload can occur from rapid infusion of intravenous fl uids administered if the client is experiencing hemor- rhage or shock. It is not associated with prolonged latent phase. The client's membranes are intact, so it would be diffi cult to assess meconium staining of the fl uid. Meconium-stained fl uid is associated with fetal distress, and this fetus appears to be in a healthy state, as evidenced by a fetal heart rate within normal range and good variability. CN: Reduction of risk potential; CL: Analyze

31. After reinforcing the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statements would demonstrate her understanding of when to call the physician's offi ce? Select all that apply. ■ 1. "If I get up in the morning and feel dizzy, even if the dizziness goes away." ■ 2. "If I see any bleeding, even if I have no pain." ■ 3. "If I have a pounding headache that doesn't go away." ■ 4. "If I notice the veins in my legs getting bigger." ■ 5. "If the leg cramps at night are waking me up." ■ 6. "If the baby seems to be more active than usual."

31. 2, 3, 6. Vaginal bleeding with or without pain could signify placenta previa or abruptio placentae. Continuous or pounding headache could indicate an elevated blood pressure, and change in the strength or frequency of fetal movements could indicate that the fetus is in distress. Orthos- tatic hypotension can occur during pregnancy and can be alleviated by rising slowly. Leg veins may increase in size due to additional pressure from the increasing uterine size, while leg cramps may also occur and can commonly be decreased with calcium supplements. CN: Reduction of risk potential; CL: Evaluate

31. An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which of the fol- lowing responses would be most appropriate? ■ 1. "Hold him when he is fussy or crying." ■ 2. "Hold him as much as you want to hold him." ■ 3. "Try to hold him infrequently to avoid over- stimulation." ■ 4. "You can hold him periodically throughout the day."

31. 2. According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to, sing- ing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs. Being held makes infants feel loved and cared for and should be encouraged. The mother can hold the neonate as often as she wants, not just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant. CN: Health promotion and maintenance; CL: Synthesize

31. The nurse is teaching a new prenatal client about her iron defi ciency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? ■ 1. "I will need to take iron supplements now." ■ 2. "I may have anemia because my family is of Asian descent." ■ 3. "I am considered anemic if my hemoglobin is below 11 g/dL." ■ 4. "The workload on my heart is increased when there is not enough oxygen in my system."

31. 2. Iron defi ciency anemia is caused by insuf- fi cient iron stores in the body, poor iron content in the diet of the pregnant woman, or both. Other thalassemias and sickle cell anemia, rather than iron defi ciency anemia, can be associated with ethnicity but occur primarily in clients of African American or Mediterranean origin. Because red blood cells in- crease by about 50% during pregnancy, many clients will need to take supplemental iron to avoid iron defi ciency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dL. In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells. CN: Reduction of risk potential; CL: Evaluate

32. A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occip- itoposterior (LOP) position requests pain relief for severe back pain. The nurse should: ■ 1. Provide fi rm pressure to the client's sacral area. ■ 2. Prepare the client for a cesarean delivery. ■ 3. Prepare the client for a precipitate delivery. ■ 4. Maintain the client in a left side-lying position.

32. 1. The client who has back pain during labor experiences marked discomfort because the fetus is in an LOP position. This pain is much greater than when the fetus is in the anterior position because the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application of fi rm pressure to the sacral area can help alleviate the pain. Complaints of severe back pain during labor do not typically require a cesarean delivery. The physician may elect to do an episiotomy, but it is not necessarily required. It is unlikely that a primi- gravid client with a fetus in an LOP position will have a precipitous delivery; rather, labor is usually more prolonged. A hands-and-knees position or a right side-lying position may help to rotate the fetal head and thus alleviate some of the back pain. CN: Health promotion and maintenance; CL: Synthesize

32. After instructing a mother about normal refl exes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck refl ex as occurring when the neonate does which of the following? ■ 1. Steps briskly when held upright near a fi rm, hard surface. ■ 2. Pulls both arms and does not move the chin beyond the point of the elbows. ■ 3. Turns head to the left, extends left extremi- ties, and fl exes right extremities. ■ 4. Extends and abducts the arms and legs with the toes fanning open.

32. 3. The tonic neck refl ex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremi- ties, and fl exes the right extremities. This refl ex disappears in a matter of months as the neonatal nervous system matures. The stepping refl ex is demonstrated when the infant is held upright near a hard, fi rm surface. The prone crawl refl ex is demon- strated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski refl ex. CN: Health promotion and maintenance; CL: Apply

32. The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular coagula- tion after delivering a dead fetus. Which fi ndings are the highest priority to report to the health care provider? ■ 1. Activated partial thromboplastin time (APTT) of 30 seconds. ■ 2. Hemoglobin of 11.5 g/dL. ■ 3. Urinary output of 25 mL in the past hour. ■ 4. Platelets at 149,000/mm3 .

32. 3. Urinary output of less than 30 mL/hour indicates renal compromise and would be the most important assessment fi nding to report to the health care provider. The APTT is within normal limits and the hemoglobin is lower than values for an adult female but within normal limits for a pregnant female. Although the platelet level is slightly low and may impact blood clotting, when compared to renal failure, it is less important. CN: Management of care; CL: Synthesize

32. The nurse on the night shift fi nds a mul- tiparous client, 8 hours postpartum, drenched in perspiration. The client's temperature is 99° F (36.8° C), the pulse is 68 bpm, and the blood pres- sure is 120/80 mm Hg. Which of the following nurs- ing diagnoses is a priority? ■ 1. Risk for infection (postpartum) related to birth trauma. ■ 2. Ineffective thermoregulation related to hor- monal changes. ■ 3. Ineffective tissue perfusion: Renal related to the status of multiparity. ■ 4. Excess fluid volume related to normal post- partal diuresis.

32. 4. Excessive perspiration and diuresis is common during the puerperium as the body attempts to return to its prepregnant state. The most appropriate nursing diagnosis is Excess fl uid volume related to normal postpartal diuresis. A temperature of 99° F (37.2° C) is normal during the fi rst 24 hours postpartum. Foul-smelling lochia and a tempera- ture higher than 100.4° F (38° C) would suggest an infection. Although hormonal shifts occur during the postpartum period, the client's diaphoresis is related to diuresis, not to a problem with thermoreg- ulation caused by hormonal changes. No evidence is presented to suggest altered renal tissue perfusion related to the client's multiparity status. Clients with renal disease or renal failure may exhibit painful urination, fl ank pain, or lack of urinary output. CN: Health promotion and maintenance; CL: Analyze

32. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which of the following information about changes the client can anticipate in the first trimester? ■ 1. Differentiating the self from the fetus. ■ 2. Enjoying the role of nurturer. ■ 3. Preparing for the reality of parenthood. ■ 4. Experiencing ambivalence about pregnancy.

32. 4. Many women in their fi rst trimester feel ambivalent about being pregnant because of the signifi cant life changes that occur for most women who have a child. Ambivalence can be expressed as a list of positive and negative consequences of having a child, consideration of fi nancial and social implications, and possible career changes. During the second trimester, the infant becomes a separate individual to the mother. The mother will begin to enjoy the role of nurturer postpartum. During the third trimester, the mother begins to prepare for parenthood and all of the tasks that parenthood includes. CN: Health promotion and maintenance; CL: Apply

33. A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to which of the following? ■ 1. Rapid, shallow chest breathing. ■ 2. Deep chest breathing. ■ 3. Rapid pant-blow breathing. ■ 4. Slow abdominal breathing.

33. 1. The psychoprophylaxis method of child- birth suggests using slow chest breathing until it becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70 breaths per minute. Deep chest breathing is appropriate for the early phase of labor, in which the client exhibits less frequent contractions. When transition nears, a rapid pant-blow pattern of breath- ing is used. Slow abdominal breathing is very dif- fi cult for clients in labor. CN: Health promotion and maintenance; CL: Apply

33. A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus? ■ 1. The neonate's eyes are unable to focus on light at this time. ■ 2. Neonates commonly lack eye muscle coordination. ■ 3. Congenital cataracts may be present. ■ 4. The neonate is able to fi xate on distant objects immediately.

33. 2. Convergent strabismus is common dur- ing infancy until about age 6 months because of poor oculomotor coordination. The neonate has peripheral vision and can fi xate on close objects for short periods. The neonate can also perceive colors, shapes, and faces. Neonates can focus on light and should blink or close their eyes in response to light. However, this is not associated with strabismus. An absent red refl ex or white areas over the pupils, not strabismus, may indicate congenital cataracts. Most neonates cannot focus well or accommodate for distance immediately after birth. CN: Health promotion and maintenance; CL: Apply

33. A 24-year-old client, G 3, P 1, at 32 weeks' gestation, is admitted to the hospital because of vaginal bleeding. After reviewing the client's his- tory, which of the following factors might lead the nurse to suspect abruptio placentae? ■ 1. Several hypotensive episodes. ■ 2. Previous low transverse cesarean delivery. ■ 3. One induced abortion. ■ 4. History of cocaine use.

33. 4. Although the exact cause of abruptio placentae is unknown, possible contributing fac- tors include excessive intrauterine pressure caused by hydramnios or multiple pregnancy, cocaine use, cigarette smoking, alcohol ingestion, trauma, increased maternal age and parity, and amniotomy. A history of hypertension is associated with an increased risk of abruptio placentae. A previous low transverse cesarean section delivery and a his- tory of one induced abortion are associated with increased risk of placenta previa, not abruptio placentae. CN: Physiological adaptation; CL: Analyze

33. An antenatal primagravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruc- tion when she indicates carrying twins puts her at risk for which of the following? ■ 1. Preterm labor. ■ 2. Twin-to-twin transfusion. ■ 3. Anemia. ■ 4. Group B Streptococcus.

33. 4. Group B Streptococcus is a risk factor for all pregnant women and is not limited to those car- rying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation. The normal uterus is only able to distend to a certain point and when that point is reached, labor may be initiated. Twin-to-twin trans- fusion drains blood from one twin to the second and is a problem that may occur with multiple gestation. The donor twin may become growth restricted and can have oligohydramnios while the recipient twin may become polycythemic with polyhydramnios and develop heart failure. Anemia is a common problem with multiple gestation clients. The mother is commonly unable to consume enough protein, calcium, and iron to supply her needs and those of the fetuses. A maternal hemoglobin level below 11 g/dL is considered anemic. CN: Physiological adaptation; CL: Evaluate

33. On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the cli- ent for: ■ 1. Puerperal infection. ■ 2. Vaginal lacerations. ■ 3. History of drug abuse. ■ 4. Perineal hematoma.

33. 4. If the client continues to complain of perineal pain after an analgesic medication has been given, the nurse should inspect the client's perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a nonsteroi- dal anti-infl ammatory medication used to relieve mild pain. Pain from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic, such as acetaminophen with codeine (Tylenol with Codeine). Ice applied to the perineum during the fi rst 24 hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such as a sitz bath three times daily for 20 minutes, also can help to relieve the discomfort when implemented after the fi rst 24 hours. Typically hematomas resolve themselves within 6 weeks. A puerperal infection would be indicated if the cli- ent's temperature were 100.4° F (41° C) or higher. Also, lochia most likely would be foul smelling. A continuous trickle of lochia rubra would suggest a possible vaginal laceration. No evidence is pre- sented to suggest a history of drug abuse. CN: Reduction of risk potential; CL: Analyze

34. The nurse assigns an individual who is an unlicensed assistive personnel to care for a client who is one day postpartum. Which of the follow- ing would be appropriate to delegate to this person? Select all that apply. ■ 1. Changing the perineal pad and reporting the drainage. ■ 2. Assisting the mother to latch the infant onto the breast. ■ 3. Checking the location of the fundus prior to ambulating the client. ■ 4. Reinforcing good hygiene while assisting the client with washing the perineum. ■ 5. Discussing postpartum depression with the client who is found crying. ■ 6. Assisting the client with ambulation shortly after delivery.

34. 1, 4, 6. Delegating care to unlicensed assistive personnel requires that the nurse knows which tasks are within their capability. Changing the perineal pad and reporting drainage, reinforcing hygiene with perineal care, and assisting with ambulation are within the individual's capacity. Unlicensed assistive personnel should never be asked to com- plete any assessments, such as checking fundal loca- tion or performing skilled procedures on a client. In addition, it would be above the scope for unlicensed assistive personnel to assist the mother with latch- ing on and discussing postpartum depression with the client. State boards of nursing list the proce- dures and tasks that unlicensed assistive personnel can complete when directed. CN: Management of care; CL: Synthesize

34. A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experi- encing enlargement of her abdomen, a positive preg- nancy test, and changes in the pigmentation on her face and abdomen. These assessment fi ndings refl ect this woman is experiencing a cluster of which signs of pregnancy? ■ 1. Positive. ■ 2. Probable. ■ 3. Presumptive. ■ 4. Diagnostic.

34. 2. The plan of care should refl ect that this woman is experiencing probable signs of pregnancy. She may be pregnant but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease processes as well as pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound con- fi rmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word "diagnostic" is not used to describe the condition of pregnancy. CN: Physiological adaptation; CL: Analyze

34. When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation (DIC)? ■ 1. Ringer's lactate solution. ■ 2. Fresh frozen platelets. ■ 3. 5% dextrose solution. ■ 4. Warfarin sodium (Coumadin).

34. 2. Treatment of DIC includes treating the causative factor, replacing maternal coagulation fac- tors, and supporting physiologic functions. Intrave- nous infusions of whole blood, fresh-frozen plasma, or platelets are used to replace depleted maternal coagulation factors. Although Ringer's lactate solu- tion and 5% dextrose solution may be used as in- travenous fl uid replacement, the client needs blood component therapy. Therefore, normal saline must be used. Intravenous heparin, not warfarin sodium (Coumadin) may be administered to halt the clotting cascade. CN: Physiological adaptation; CL: Analyze

34. While performing a physical assessment on a term neonate shortly after birth, which of the follow- ing would cause the nurse to notify the pediatrician? ■ 1. Deep creases across the soles of the feet. ■ 2. Frequent sneezing during the assessment. ■ 3. Single crease on each of the palms. ■ 4. Absence of lanugo on the skin.

34. 3. A single crease across the palm (simian crease) is most commonly associated with chromo- somal abnormalities, notably Down syndrome. Deep creases across the soles of the feet is a normal fi nd- ing in a term neonate. Frequent sneezing in a term neonate is normal. This occurs because the neonate is a nose breather and sneezing helps to clear the nares. An absence of lanugo on the skin of a term neonate is a normal fi nding. CN: Reduction of risk potential; CL: Synthesize

34. A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gesta- tion. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appear- ing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for: ■ 1. Metabolic alkalosis. ■ 2. Metabolic acidosis. ■ 3. Respiratory alkalosis. ■ 4. Respiratory acidosis.

34. 3. The carbon dioxide insuffi ciency that occurs during hyperventilation will lead to respiratory alka- losis. Symptoms include confusion, unconsciousness, elevated plasma pH (greater than 7.45), and elevated urine pH (above 7). The nurse should try to calm the client and, if the hyperventilation persists, should ask the client to breathe into a paper bag. Metabolic alka- losis is associated with vomiting when a large amount of hydrochloric acid is lost. Metabolic acidosis is associated with loss of sodium ions through diar- rhea. Respiratory acidosis is associated with shallow breathing and an inability to expire completely. CN: Reduction of risk potential; CL: Analyze

35. Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management? Select all that apply. ■ 1. "My baby can't have milk-based formulas." ■ 2. "My baby will grow out of this by the age of 2." ■ 3. "This is a hereditary disease, so any future children will have it, too." ■ 4. " My baby will eventually become retarded because of this disease." ■ 5. "We have to follow a strict phenylalanine diet." ■ 6. "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."

35. 1, 5, 6. Phenylketonuria, an inherited auto- somal recessive disorder, involves the body's inabil- ity to metabolize the amino acid phenylalanine. A diet low in phenylalanine must be followed. Such foods as meats, eggs, and milk are high in phenylala- nine. Assistance from a dietitian is commonly neces- sary to keep phenylalanine levels low and to provide the essential amino acids necessary for cell function and tissue growth. With autosomal recessive dis- orders, future children will have a 25% chance of having the disease, a 50% chance of carrying the dis- ease, and a 35% chance of being free of the disease. If a diet low in phenylalanine is followed until brain growth is complete (sometime in adolescence), the child should achieve normal intelligence. CN: Health promotion and maintenance; CL: Evaluate

35. When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moder- ate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present? ■ 1. Painless vaginal bleeding. ■ 2. Uterine tetany. ■ 3. Intermittent pain with spotting. ■ 4. Dull lower back pain.

35. 1. The most common assessment fi nding associated with placenta previa is painless vaginal bleeding. With placenta previa, the placenta is abnormally implanted, covering a portion or all of the cervical os. Uterine tetany, intermittent pain with spotting, and dull lower back pain are not associated with placenta previa. Uterine tetany is associated with oxytocin administration. Intermit- tent pain with spotting commonly is associated with a spontaneous abortion. Dull lower back pain is commonly associated with poor maternal posture or a urinary tract infection with renal involvement. CN: Physiological adaptation; CL: Analyze

35. The physician orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose? ■ 1. Assessment of the fetal hematocrit level. ■ 2. Increase in the strength of the contractions. ■ 3. Increase in the fetal heart rate and variability. ■ 4. Assessment of fetal position.

35. 3. Fetal scalp stimulation is commonly ordered when there is decreased fetal heart rate vari- ability. Pressure is applied with the fi ngers to the fetal scalp through the dilated cervix. This should cause a tactile response in the fetus and increase the fetal heart rate and variability. However, if the fetus is in distress and becoming acidotic, fetal heart rate accel- eration will not occur. The fetal hematocrit level can be measured by fetal blood sampling. Scalp stimula- tion does not increase the strength of the contractions. However, it can increase fetal heart rate and vari- ability. Fetal position is assessed by identifying skull landmarks (sutures) during a vaginal examination. CN: Reduction of risk potential; CL: Apply

35. An antenatal client receives education concerning medications that are safe to use during pregnancy. The nurse evaluates the client's under- standing of the instructions and determines that she needs further information when she states which of the following? ■ 1. "If I am constipated, Milk of Magnesia is okay but mineral oil is not." ■ 2. "If I have heartburn, it is safe to use Tums, Rolaids, Mylanta, and Maalox." ■ 3. "I can take Tylenol if I have a headache." ■ 4. "If I need to have a bowel movement, Ex-Lax is preferred."

35. 4. Ex-Lax is considered too abrasive to use during pregnancy. In most instances, a Fleet enema will be given before Ex-Lax. Medications for con- stipation that are considered safe during pregnancy include compounds that produce bulk, such as Metamucil and Citrucel. Colace, Dulcolax, and Milk of Magnesia can also be used. Mineral oil prevents the absorption of vitamins and minerals within the GI tract. The strategies for heartburn are considered safe and Tylenol may be used as an over-the-counter analgesic. CN: Pharmacological and parenteral therapies; CL: Evaluate

35. While the nurse is caring for a primiparous client on the fi rst postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which of the following responses by the nurse would be most appropriate? ■ 1. Ignore the client's question and continue with morning care. ■ 2. Tell the client "I'm not sure how the other woman is doing today." ■ 3. Tell the client "I need to ask the woman's permission before discussing her well-being." ■ 4. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."

35. 4. The Health Information Portability and Accountability Act (HIPAA) regulations and ethi- cal decision making require that the nurse main- tain confi dentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the devel- opment of a trusting nurse-client relationship. Confi dentiality must be maintained at all times. Telling the client that the nurse isn't sure may imply that the nurse will fi nd out and then tell the client about the other woman. Asking the other woman's permission to discuss her with another client is inappropriate because confi dentiality must be main- tained at all times. CN: Management of care; CL: Apply

36. Assessment of a term neonate at 2 hours after birth reveals a heart rate of 110 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifi es the pediatrician based on the interpretation that these fi ndings may lead to which condition? ■ 1. Respiratory arrest. ■ 2. Bronchial pneumonia. ■ 3. Intraventricular hemorrhage. ■ 4. Epiglottitis.

36. 1. Periods of apnea lasting longer than 20 seconds, mild cyanosis, and a heart rate of 110 bpm (bradycardia) are associated with a potentially life- threatening event and subsequent respiratory arrest. The neonate needs further evaluation by the pedia- trician. Pneumonia is associated with tachycardia, anorexia, malaise, cyanosis, diminished breath sounds, and crackles. Intraventricular hemorrhage is associated with prematurity. Assessment fi ndings include bulging fontanels and seizures. Epiglottitis is a bacterial form of croup. Assessment fi ndings include inspiratory stridor, cough, and irritability. It occurs most commonly in children age 3 to 7 years. CN: Reduction of risk potential; CL: Analyze

36. When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay preg- nancy test, the nurse should tell the client which of the following about this test? ■ 1. It has a high degree of accuracy within 1 week after ovulation. ■ 2. It is identical in nature to an over-the-counter home pregnancy test. ■ 3. A positive result is considered a presumptive sign of pregnancy. ■ 4. A urine sample is needed to obtain quicker results.

36. 1. The radioimmunoassay pregnancy test, which uses an antiserum with specifi city for the b-subunit of human chorionic gonadotrophin (hCG) in blood plasma, is highly accurate within 1 week after ovulation. The test is performed in a labora- tory. Over-the-counter or home pregnancy tests are performed on urine and use the hemagglutination inhibition method. Radioimmunoassay tests usu- ally use blood serum. A positive pregnancy test is considered a probable sign of pregnancy. Certain conditions other than pregnancy, such as choriocar- cinoma, can cause increased hCG levels. CN: Reduction of risk potential; CL: Apply

36. After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effec- tive when the client says that the bleeding results from which of the following? ■ 1. Diminished clotting factors. ■ 2. Exposure of maternal blood sinuses. ■ 3. Increased platelet levels. ■ 4. A large-for-gestational-age fetus.

36. 2. Bleeding precipitated by placenta pre- via results from exposure of the maternal sinuses when placental villi are torn from the uterine wall as the lower uterine segment contracts and dilates in the later weeks of pregnancy. The bleed- ing is not initiated because of diminished clotting factors. Diminished clotting factors are associ- ated with DIC. Increased platelet levels would suggest an increased risk for clotting. A large-for- gestational-age fetus may be related to hereditary factors or diabetes. CN: Physiological adaptation; CL: Evaluate

36. A newly delivered primiparous client asks the nurse, "Can my baby see?" Which of the fol- lowing statements about neonatal vision should the nurse include in the explanation? ■ 1. Neonates primarily focus on moving objects. ■ 2. They can see objects up to 12 inches away. ■ 3. Usually they see clearly by about 2 days after birth. ■ 4. Neonates primarily distinguish light from dark.

36. 2. The neonate has immature oculomotor coordination, an inability to accommodate for dis- tance, and poorly developed eyes, visual nerves, and brain. However, the normal neonate can see objects clearly within a range of 9 to 12 inches, whether or not they are moving. Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Newborns can distinguish colors as well as light from dark. CN: Health promotion and maintenance; CL: Apply

36. The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following? ■ 1. 7.5. ■ 2. 7.4. ■ 3. 7.3. ■ 4. 7.2.

36. 4. If the fetus is hypoxic, the pH will fall below 7.2 and be indicative of fetal distress. This fi nding typically requires immediate vaginal or cesarean delivery. A scalp pH reading of 7.21 to 7.25 should be repeated again in 30 minutes for assess- ment of hypoxia and acidosis. CN: Physiological adaptation; CL: Analyze

37. The physician orders whole blood replace- ment for a multigravid client with abruptio placen- tae. Before administering the intravenous blood product, the nurse should fi rst: ■ 1. Validate client information and the blood product with another nurse. ■ 2. Check the vital signs before transfusing over 5 to 6 hours. ■ 3. Ask the client if she has ever had any aller- gies. ■ 4. Administer 100 mL of 5% dextrose solution intravenously.

37. 1. When administering blood replacement therapy, extreme caution is needed. Before adminis- tering any blood product, the nurse should validate the client information and the blood product with another nurse to prevent administration of the wrong blood transfusion. Although baseline vital signs are necessary, she should initiate the infusion of blood slowly for the fi rst 10 to 15 minutes. Then, if there is no evidence of a reaction, she should adjust the rate of infusion to ensure that the blood product is infused over 2 to 4 hours. The nurse can ask the client if she has ever had a reaction to a blood product, but a general question about allergies may not elicit the most complete response about any reactions to blood product administra- tion. Blood transfusions are typically given with intravenous normal saline solution, not dextrose solutions. CN: Pharmacological and parenteral therapies; CL: Apply

37. Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client complains of severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in a position that is identifi ed as which of the following? ■ 1. Breech. ■ 2. Transverse. ■ 3. Posterior. ■ 4. Anterior.

37. 3. When a client complains of severe back pain during labor, the fetus is most likely in an occipitoposterior position. This means that the fetal head presses against the client's sacrum, caus- ing marked discomfort during contractions. These sensations may be so intense that the client requests medication for relief of the back pain rather than the contractions. Breech presentation and transverse lie are usually known prior to 8-cm dilation and a cesarean section is performed. Fetal occiput anterior position does not increase the pain felt during labor. CN: Health promotion and maintenance; CL: Apply

37. A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about? ■ 1. 2 to 3 months. ■ 2. 6 to 8 months. ■ 3. 9 to 10 months. ■ 4. 12 to 18 months.

37. 4. Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in mental retardation. The posterior fontanel typi- cally closes by ages 2 to 3 months. CN: Health promotion and maintenance; CL: Apply

37. While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client: ■ 1. She will have a surgical repair at 6 weeks postpartum. ■ 2. To remain on bed rest until resolution occurs. ■ 3. The separation will resolve on its own with the right posture and diet. ■ 4. To perform exercises involving head and shoulder raising in a lying position.

37. 4. The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of the abdomen that is usually palpable on the third post- partum day. An exercise involving raising the head and shoulders about 8 inches with the client lying on her back with knees bent and hands crossed over the abdomen is preferred. This exercise helps to pull the abdominal muscles together and the cli- ent gradually works up to performing this exercise 50 times per day. However, until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or bend the trunk to one side, because further separation may occur. The con- dition does not need a surgical repair, and limited activity and bed rest are not necessary. Correct pos- ture and adequate diet assist the body to return to its prepregnancy state more quickly but do not resolve the separation of abdominal muscles. CN: Reduction of risk potential; CL: Synthesize

37. After instructing a female client about the radioimmunoassay pregnancy test, the nurse deter- mines that the client understands the instructions when the client states that which of the following hormones is evaluated by this test? ■ 1. Prolactin. ■ 2. Follicle-stimulating hormone. ■ 3. Luteinizing hormone. ■ 4. Human chorionic gonadotropin (hCG).

37. 4. The hormone analyzed in most pregnancy tests is hCG. In the pregnant woman, trace amounts of hCG appear in the serum as early as 24 to 48 hours after implantation owing to the trophoblast production of this hormone. Prolactin, follicle- stimulating hormone, and luteinizing hormone are not used to detect pregnancy. Prolactin is the hor- mone secreted by the pituitary gland to prepare the breasts for lactation. Follicle-stimulating hormone is involved in follicle maturation during the menstrual cycle. Luteinizing hormone is responsible for stimu- lating ovulation. CN: Reduction of risk potential; CL: Evaluate

38. The nurse assesses a primiparous client in labor for 20 hours. The nurse identifi es late decel- erations on the monitor and initiates standard pro- cedures for the labor client with this wave pattern. Which interventions should the nurse perform? Select all that apply. ■ 1. Administering oxygen via mask to the client. ■ 2. Questioning the client about the effectiveness of pain relief. ■ 3. Placing the client on her side. ■ 4. Readjusting the monitor to a more comfort- able position. ■ 5. Applying an internal fetal monitor to help identify the cause of the decelerations.

38. 1, 3, 5. Decelerations alert the nurse that the fetus is experiencing decreased blood fl ow from the placenta. Administering oxygen will increase tis- sue perfusion. Placing the mother on her side will increase placental perfusion and decrease cord com- pression. Using an internal fetal monitor would help in identifying the possible underlying cause of the decelerations, such as metabolic acidosis. Assessing for pain relief and readjusting the monitor would have no effect on correcting the late decelerations. CN: Reduction of risk potential; CL: Synthesize

38. Which of the following assessment fi ndings in a term neonate would cause the nurse to notify the pediatrician? ■ 1. Absence of tears. ■ 2. Unequally sized corneas. ■ 3. Pupillary constriction to bright light. ■ 4. Red circle on pupils with ophthalmoscopic examination.

38. 2. Corneas of unequal size should be reported because this may indicate congenital glaucoma. An absence of tears is common because the neonate's lacrimal glands are not yet functioning. The neo- nate's pupils normally constrict when a bright light is focused on them. The fi nding implies that light perception and visual acuity are present, as they should be after birth. A red circle on the pupils is seen when an ophthalmoscope's light shines onto the retina and is a normal fi nding. Called the red refl ex, this indicates that the light is shining onto the retina. CN: Reduction of risk potential; CL: Syntehsize

38. Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following? ■ 1. The client will most likely have postpartum blues. ■ 2. Maternal-infant bonding is likely to be diffi cult. ■ 3. The client's feeling of grief is a normal reaction. ■ 4. This type of delivery was necessary to save the client's life.

38. 3. Feelings of loss, grief, and guilt are nor- mal after a cesarean section delivery, particularly if it was not planned. The nurse should support the client, listen with empathy, and allow the client time to grieve. The likelihood of the client expe- riencing postpartum blues is not known, and no evidence is presented. Although maternal-infant bonding may be delayed owing to neonatal compli- cations or maternal pain and subsequent medica- tions, it should not be diffi cult. Although the nurse is aware that that this type of delivery was neces- sary to save the client's life, using this as the basis for the response does not acknowledge the mother's feelings. CN: Psychosocial adaptation; CL: Apply

41. The health care provider has determined that a preterm labor client at 34 weeks' gestation has no fetal fi bronectin present. The nurse should assess the client for which of the following outcomes in the next week? ■ 1. The client will develop preeclampsia. ■ 2. The fetus will develop mature lungs. ■ 3. The client will not likely develop preterm labor. ■ 4. The fetus will not develop gestational diabetes.

41. 3. The absence of fetal fi bronectin in a vaginal swab between 22 and 37 weeks' gestation indicates there is less than 1% risk of developing preterm la- bor in the next week. Fetal fi bronectin is an extra cel- lular protein normal found in fetal membranes and deciduas and has no correlation with preeclampsia, fetal lung maturation, or gestational diabetes. CN: Reduction of risk potential; CL: Synthesize

38. A postpartum client delivered 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus 2 fi ngerbreadths above the umbilicus and off to the right side. What should the nurse do fi rst? ■ 1. Administer ibuprofen (Motrin). ■ 2. Reassess in 1 hour. ■ 3. Catheterize the client. ■ 4. Administer an I.V. bolus of 500 mL to rehy- drate per policy.

38. 4. A uterine fundus located off to one side and above the level of the umbilicus is commonly the result of a full bladder. Although the client had voided, the client may be experiencing urinary retention with overfl ow. If anesthesia has been used for delivery, the inability to void may be related to the lingering effects of anesthesia; however, that is not the case here. Physicians commonly write a one- time order for catheterization. After which, typi- cally, enough edema has subsided making it easier and less painful for the client to void and com- pletely empty her bladder. Administering ibuprofen would have no effect on the uterine fundus. Waiting to reassess in 1 hour could be detrimental since the client's distended bladder is interfering with uterine involution, predisposing her to possible hemor- rhage. Administering a bolus of fl uid would be inap- propriate because it would only add to the client's full bladder. CN: Reduction of risk potential; CL: Synthesize

38. Using Nägele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of delivery would be which of the following? ■ 1. January 13. ■ 2. January 17. ■ 3. February 13. ■ 4. February 17.

38. 4. When using Nägele's rule to determine the estimated date of delivery, the nurse would count back 3 calendar months from the fi rst day of the last menstrual period and add 7 days. This means the client's estimated date of delivery is February 17. CN: Health promotion and maintenance; CL: Apply

39. While the nurse is assessing the fundus of a multiparous client who delivered 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate? ■ 1. "As long as you don't get pregnant again, the marks will disappear completely." ■ 2. "They usually fade to a silvery-white color over a period of time." ■ 3. "You'll need to use a specially prescribed cream to help them disappear." ■ 4. "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."

39. 2. Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After delivery, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families. CN: Health promotion and maintenance; CL: Synthesize

39. At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respi- ratory rate of 35 breaths/minute. The nurse inter- prets these fi ndings as indicating that this neonate is most likely experiencing which of the following? ■ 1. Drug withdrawal. ■ 2. First period of reactivity. ■ 3. A state of deep sleep. ■ 4. Respiratory distress.

39. 3. At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/minute is normal. CN: Health promotion and maintenance; CL: Analyze

39. When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing? (pic) ■ 1. First maneuver. ■ 2. Second maneuver. ■ 3. Third maneuver. ■ 4. Fourth maneuver.

39. 3. The third maneuver involves grasping the lower portion of the abdomen just above the symphy- sis pubis between the thumb and index fi nger. This maneuver determines whether the fetal presenting part is engaged. The fi rst maneuver involves facing the woman's head and using the tips of the fi ngers to palpate the uterine fundus. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. The second maneuver involves placing the palms of each hand on either side of the abdomen to locate the back of the fetus. The fourth maneuver involves placing fi ngers on both sides of the uterus and pressing downward and inward in the direction of the birth canal. This maneuver is done to determine fetal attitude and degree of extension and should only be done if the fetus is in the cephalic presentation. CN: Physiological adaptation; CL: Apply

39. After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is pro- duced by the placenta? ■ 1. Estrogen. ■ 2. Progesterone. ■ 3. Human chorionic gonadotropin (hCG). ■ 4. Testosterone.

39. 4. The placenta does not produce testoster- one. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the pla- centa during pregnancy. The hormone hCG stimu- lates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can as- sume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi. CN: Health promotion and maintenance; CL: Evaluate

39. A client has received epidural anesthesia to control pain during a cesarean section. Place an X over the highest point on the body locating the level of anesthesia expected for a cesarean birth. *pic

39. Epidural anesthesia for a cesarean birth must be at the level of T4 to T6, approximately the nipple line. The level of anesthesia achieved via epidural anesthesia for a vaginal birth is T10 (approximately the hips). CN: Pharmacological and parenteral therapies; CL: Apply

The Preterm Neonate 41. The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of kanga- roo care include which of the following? Select all that apply. ■ 1. Facilitate a positive bonding experience. ■ 2. Increased IQ. ■ 3. Physiologic stability. ■ 4. Shorten length of stay in the neonatal inten- sive care unit. ■ 5. Time to grow.

41. 1, 3, 4. Kangaroo care is skin-to-skin hold- ing of a neonate by one of the parents. Research has shown increased bonding, physiologic stabil- ity, and decreased length of stay for neonates who experience this method of holding. Research has not shown an increase in IQ as a developmental out- come. Kangaroo care has not been shown to cause the neonate to gain weight quickly. The experi- ence is usually limited to 1 to 2 hours, 2 to 3 times per day. CN: Health promotion and maintenance; CL: Apply

4. Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on con- traceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Defi cient knowledge related to ovulation and fertility manage- ment. Which of the following would be important to include in the teaching plan for the client? ■ 1. The ovum survives for 96 hours after ovulation, making conception possible during this time. ■ 2. The basal body temperature falls at least 0.2° F after ovulation has occurred. ■ 3. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. ■ 4. Most women can tell they have ovulated because of severe pain and thick, scant cervi- cal mucus.

4. 3. For a client with a menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body tem- perature rises 0.5° to 1.0° F when ovulation occurs. Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious. CN: Health promotion and maintenance; CL: Create

4. A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should: ■ 1. Maintain continuous fetal monitoring. ■ 2. Encourage family members to remain at bedside. ■ 3. Assess refl exes, clonus, visual disturbances, and headache. ■ 4. Monitor maternal liver studies every 4 hours.

4. 3. The central nervous system (CNS) func- tioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hyperten- sion or stroke, oxygenation status is compromised and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of second- ary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assess- ment of maternal refl exes, clonus, visual disturbanc- es, and headache give clear evidence of the condi- tion of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system but the less invasive and highly correlated condition of the maternal CNS system in assessing refl exes, maternal headache, visual distur- bances, and clonus is the highest priority. Psycho- social care is a priority and can be accomplished in ways other than having the family remain at the bedside. CN: Safety and infection control; CL: Synthesize

4. The nurse is caring for a postpartum client who delivered vaginally 4 hours ago and has not voided since delivery. Feeling has returned to her perineal area, and she has ambulated to the bathroom and attempted to void twice. She has ice on her edematous perineum. Her uterus is 3 fi ngerbreadths above the umbilicus, to the right of midline, and fi rm only with massage. What is the priority nursing action? ■ 1. Evaluate the client with a bladder scan. ■ 2. Insert a Foley catheter. ■ 3. Medicate the client with a nonsteroidal anti- infl ammatory drug (NSAID). ■ 4. Massage the fundus until it is fi rm and per- form a one-time catheterization on the client.

4. 4. Uterine massage enables immediate con- traction of the uterus to prevent bleeding. In-and-out catheterization relieves bladder distention, elimi- nates displacement, fi rms the uterus, and prevents uterine bleeding. A bladder scan is not necessary because the nurse is able to palpate the full bladder. The positioning of the uterus indicates a full blad- der. An indwelling urinary catheter is not necessary because most clients spontaneously void within 12 hours. The use of an NSAID will help reduce the infl ammation that may be present but its action is not immediate and the status of the fundus needs more immediate interventions because of the risk of postpartum hemorrhage associated with a full blad- der. CN: Management of care; CL: Synthesize

73. A neonate born at 29 weeks' gestation received nasal continuous positive airway pressure. The neonate is receiving oxygen at 1 L/minute via nasal cannula at a fraction of inspired oxygen (FIO2) of 0.23. The pulse oximetry reading is 70% satura- tion. In which order of priority from fi rst to last should the nurse take these actions? 1. Increase the FiO2 2. Make sure the pulse oximeter is correlating to the heart rate. 3. Assess the neonate for color. 4. Assess the neonate for respiratory effort.

4. Assess the neonate for respiratory effort. 3. Assess the neonate for color. 2. Make sure the pulse oximeter is correlating to the heart rate. 1. Increase the FiO2 Assessment of the neonate is the most important priority and should be completed first. Respiratory effort must be assessed first to determine if the neonate is breathing. Once breathing is established, assessment of color is next. Then verifi cation of proper equipment function is necessary. The last measure is to increase the FiO2 due to the potential harmful effects of oxygen. Oxygen should be viewed as a drug and its use evaluated carefully. Increas- ing the FIO2 should be done only when indicated; possible causes of low saturation readings must be evaluated fi rst. CN: Reduction of risk potential; CL: Synthesize

40. The nurse should do which of the following actions fi rst when admitting a multigravid client at 36 weeks' gestation with a probable diagnosis of abruptio placentae? ■ 1. Prepare the client for a vaginal examination. ■ 2. Obtain a brief history from the client. ■ 3. Insert a large-gauge intravenous catheter. ■ 4. Prepare the client for an ultrasound scan.

40. 3. Abruptio placentae is a medical emer- gency because the degree of hypovolemic shock may be out of proportion to visible blood loss. On admission, the nurse should plan to fi rst insert a large-gauge intravenous catheter for fl uid replace- ment and oxygen by mask to decrease fetal anoxia. Vaginal examination usually is not performed on pregnant clients who are experiencing third-tri- mester bleeding due to abruptio placentae because it can result in damage to the placenta and further fetal anoxia. The client's history can be obtained once the client has been admitted and the intrave- nous line has been started. The goal is to get the fetus delivered, usually by emergency cesarean delivery. The nurse should also plan to monitor the client's vital signs and the fetal heart rate. Ultra- sound is of limited use in the diagnosis of abruptio placentae. CN: Reduction of risk potential; CL: Synthesize

40. The nurse assesses a woman at 24 weeks' gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the cli- ent's last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order? 1. Call the health care provider. 2. Explain that the fetal heart beat could not be found at this time. 3. Obtain different equipment and recheck. 4. Ask client if baby is or has been moving.

40. 4,3,2,1. While initially continuing to attempt to fi nd the fetal heart beat, the nurse can ask the client if the baby has been moving. This will give a quick idea of status. The next step would be to obtain different equipment and attempt to fi nd the fetal heart beat again. A simple statement of fact that the nurse cannot fi nd the heartbeat and is taking steps to rule out equipment error is appropriate. Calling the health care provider would be the last step after it is determined that the baby does not have a heartbeat. CN: Reduction of risk potential; CL: Synthesize

40. While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The physician is notifi ed because the nurse suspects which of the following? ■ 1. Phimosis. ■ 2. Hydrocele. ■ 3. Epispadias. ■ 4. Hypospadias.

40. 4. The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is cor- rected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swell- ing of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy. CN: Reduction of risk potential; CL: Analyze

41. A primiparous client at 10 weeks' gestation questions the nurse about the need for an ultra- sound. She states "I don't have health insurance and I can't afford it. I feel fi ne, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply. ■ 1. "We must view the gross anatomy of the fetus." ■ 2. "We need to determine gestational age." ■ 3. "We want to view the heart beating to deter- mine that the fetus is viable." ■ 4. "We must determine fetal position." ■ 5. "We must determine that there is a suffi cient nutrient supply for the fetus."

41. 1, 2. Although ultrasounds are not consid- ered part of routine care, the ultrasound is able to confi rm the pregnancy, identify the major anatomic features of the fetus and possible abnormalities, and determine the gestational age by measuring crown- to-rump length of the embryo during the fi rst trimes- ter. At this time, the ultrasound cannot confi rm the fetus is viable. The ultrasound will provide informa- tion about fetal position; however, this information would be more important later in the pregnancy, not during the fi rst trimester. The ultrasound would provide no information about nutrient supply for the fetus. CN: Health promotion and maintenance; CL: Analyze

41. An adolescent primiparous client at 24 hours postpartum tells the nurse that she and her baby will be living with her boyfriend's parents so that she can fi nish high school and go on to col- lege. The client's boyfriend and parents have been supportive of the client and neonate. Which of the following is an appropriate nursing diagnosis at this time? ■ 1. Anxiety related to return to high school and peer pressure. ■ 2. Ineffective coping related to inability to view motherhood realistically. ■ 3. Readiness for enhanced family coping, related to the addition of a new family member. ■ 4. Defi cient knowledge related to the fi nancial and emotional costs of childrearing.

41. 3. The most appropriate nursing diagnosis based on the information provided is Readiness for enhanced family coping, related to the addition of a new family member. Based on the scenario, the cli- ent has the support of the boyfriend and his parents. A nursing diagnosis of Anxiety would be appropriate if the client verbalized anxious thoughts or feelings or worries about the situation. A nursing diagnosis of Ineffective coping would be appropriate if the client showed little interest in the neonate or in mothering behaviors. A nursing diagnosis of Defi cient knowl- edge would be appropriate if the client expressed concerns about the fi nancial and emotional costs of child rearing or questions about caring for the child. CN: Psychosocial adaptation; CL: Analyze

41. A primigravid client in active labor with a fetus in LOP position complains of severe back pres- sure. Which of the following would be the priority nursing diagnosis for this client? ■ 1. Anxiety related to fear of maternal-fetal out- comes. ■ 2. Ineffective coping related to lack of experi- ence in labor. ■ 3. Urinary retention related to prolonged labor process. ■ 4. Pain related to occipitoposterior position and prolonged fetal descent.

41. 4. The priority nursing diagnosis at this time is Pain related to LOP position and prolonged fetal descent. When the fetus is in this position, the fetal head presses against the client's sacrum, caus- ing marked discomfort during contractions. Labor is usually longer and more uncomfortable when the fetus remains in an occipitoposterior position. Anxiety would be an appropriate nursing diagnosis if the client had stated that she was nervous, appre- hensive, afraid, fearful, or restless. Ineffective coping would be appropriate if the client exhibited a loss of control, screaming, crying, or thrashing around in the bed. Urinary retention might be a related nursing diagnosis; however, if the nurse is vigilant in assess- ment of the client's bladder status, the client should void at least every 2 hours or have a catheterization performed. A full bladder can impair fetal descent and prolong labor. CN: Health promotion and maintenance; CL: Analyze

42. A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a mid- line episiotomy and repair of a third-degree lac- eration. When preparing the client for discharge, which of the following assessments would be most important? ■ 1. Constipation. ■ 2. Diarrhea. ■ 3. Excessive bleeding. ■ 4. Rectal fi stulas.

42. 1. The client with a third-degree lacera- tion should be assessed for constipation, because a third-degree laceration extends into a portion of the anal sphincter. Constipation, not diarrhea, is more likely because this condition is extremely painful, possibly causing the client to be reluctant to have a bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum. Rectal fi stulas may develop at a later time, but not at 48 hours postpartum. CN: Reduction of risk potential; CL: Create

42. A neonate at 37 weeks' gestation is delivered by cesarean delivery because of placenta previa. Which of the following would the circulating nurse do fi rst as soon as the neonate is delivered? ■ 1. Stimulate the neonate to cry vigorously. ■ 2. Aspirate mucus from the mouth with a bulb syringe. ■ 3. Begin resuscitation procedures with a bag and mask. ■ 4. Hold the neonate upright for the mother to view.

42. 2. The fi rst step after cesarean delivery is to aspirate mucus from the neonate's mouth. If this is not done, the neonate will aspirate mucus when beginning to breathe. A patent airway is most important. Once mucus has been aspirated, the neonate may be stimulated to cry if necessary. If, once the airway has been established, the neonate does not begin breathing efforts on his or her own, then resuscitation may be necessary. Although the mother will want to see the neonate, holding the neonate upright is inappropriate because the neo- nate's head should be kept lower than the rest of the body to aid in the expulsion of mucus or other fl uids. CN: Health promotion and maintenance; CL: Synthesize

42. A 20-year-old married client with a positive pregnancy test states, "Is it really true? I can't believe I'm going to have a baby!" Which of the following responses by the nurse would be most appropriate at this time? ■ 1. "Would you like some booklets on the preg- nancy experience?" ■ 2. "Yes it is true. How does that make you feel?" ■ 3. "You should be delighted that you are pregnant." ■ 4. "Weren't you and your husband trying to have a baby?"

42. 2. This client is expressing a feeling of sur- prise about having a baby. Therefore, the nurse's best response would be to confi rm the pregnancy, which is something that the client already suspects, and then ascertain how the client is feeling now that the suspicion is confi rmed. Studies have shown that a common reaction to pregnancy is summarized as ambivalence or "someday, but not now." Such feelings are normal and are experienced by many women early in pregnancy. Offering a pamphlet on pregnancy does not respond to the client's feel- ings. Telling the client that she should be delighted ignores, rather than addresses, the client's feelings. Also, doing so imposes the nurse's opinion on the client. Ambivalence is a common reaction to preg- nancy. Telling the client that she should be delight- ed may lead to feelings of guilt. Asking the client if she and her husband were trying to have a baby is a "yes-no" question and is not helpful. In addition, it ignores the client's underlying feelings. CN: Psychosocial adaptation; CL: Synthesize

85. A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age? ■ 1. 2 months. ■ 2. 6 months. ■ 3. 8 months. ■ 4. 10 months.

85. 2. Pediatricians recommend that infants be given either breast milk or formula until at least 6 months of age because of the neonate's diffi culty digesting solid foods. Giving solid foods too early can lead to food allergies. Because chewing move- ments do not begin until 7 to 9 months of age, foods requiring chewing should be delayed until this time. CN: Health promotion and maintenance; CL: Apply

42. One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primi- gravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the fol- lowing would the nurse do fi rst? ■ 1. Continue to monitor the client's fundus every 15 minutes. ■ 2. Ask the physician for an order for methyler- gonovine (Methergine). ■ 3. Immediately notify the physician of the cli- ent's symptoms. ■ 4. Change the client's perineal pads every 15 minutes.

42. 3. Small clots that are expressed during fundal examination in the immediate postpartum period are normal; however, large clots are indica- tive of retained placental tissue. A small trickle of bright red vaginal bleeding may indicate a lacera- tion. The nurse should notify the physician imme- diately of these fi ndings, because uterine atony may occur and the laceration, if present, needs to be repaired to prevent further blood loss. Continuing to monitor the client every 15 minutes is the standard of care for a postpartum client. Taking no action would indicate that the nurse thinks passage of clots and trickling of bright red blood is a normal situa- tion, which it is not. Methylergonovine is a power- ful drug that contracts the uterus, but it usually is not administered to a client with a blood pressure of 136/92 mm Hg because of its hypertensive effects. Changing the perineal pads every 15 minutes is not helpful if the client is experiencing a hemorrhage. CN: Health promotion and maintenance; CL: Synthesize

42. A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following? ■ 1. "I need to stay hydrated all the time." ■ 2. "I need to avoid any infections." ■ 3. "I should include frequent rest breaks if we travel." ■ 4. "Changing to filter cigarettes is helpful."

42. 4. Smoking in any form is contraindicated in pregnancy, regardless of the type of fi ltering system used. Smoking is a major risk factor for preterm labor and decreased fetal weight. Dehydration is a risk fac- tor for preterm labor as is prolonged standing and re- maining in one position. Infection is thought to be a primary cause of preterm labor and the client would need to avoid contracting any type of infection. While taking trips, frequent emptying of the bladder prevents infection and ambulates the woman. CN: Management of care; CL: Evaluate

43. A multigravid client at 34 weeks' gestation is being treated with indomethacin (Indocin) to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following? ■ 1. Pulmonary hypertension. ■ 2. Respiratory distress syndrome (RDS). ■ 3. Hyperbilirubinemia. ■ 4. Cardiomyopathy.

43. 1. Indomethacin (Indocin) has been success- fully used to halt preterm labor. However, if the cli- ent should deliver a preterm infant, the nurse would notify the nursery personnel about the tocolytic therapy because this drug can lead to premature closure of the fetal ductus arteriosus, resulting in pulmonary hypertension. Prematurity is associated with RDS because of the immaturity of the fetal lungs. RDS is not a result of indomethacin. Hyper- bilirubinemia is more common in preterm infants. Use of indomethacin to halt preterm labor is not associated with cardiomyopathy in the infant. CN: Pharmacological and parenteral therapies; CL: Synthesize

The Multigravid Client in Labor 43. A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have vari- able decelerations to 100 to 110 bpm. What should the nurse do next? ■ 1. Perform a vaginal examination. ■ 2. Notify the physician of the decelerations. ■ 3. Reposition the client and continue to evaluate the tracing. ■ 4. Administer oxygen via mask at 2 L/minute.

43. 3. The cause of variable decelerations is cord compression, which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, oxygen should be initiated but the rate should be 8 to 10 L/minute. Notifying the physician should occur if turning the client and administering oxygen do not relieve the decelerations. CN: Management of care; CL: Synthesize

43. A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, I'm not sure I want to be pregnant!" The nurse inter- prets the client's statement as an indication of which of the following? ■ 1. Fear of pregnancy outcome. ■ 2. Rejection of the pregnancy. ■ 3. Normal ambivalence. ■ 4. Inability to care for the newborn.

43. 3. Women normally experience ambivalence when pregnancy is confi rmed, even if the pregnancy was planned. Although the client's culture may play a role in openly accepting the pregnancy, most new mothers who have been ambivalent initially accept the reality by the end of the fi rst trimester. Ambiva- lence also may be expressed throughout the preg- nancy; this is believed to be related to the amount of physical discomfort. The nurse should become concerned and perhaps contact a social worker if the client expresses ambivalence in the third trimes- ter. The client's statement refl ects ambivalence, not fear. There is no evidence to suggest or imply that the client is rejecting the fetus. The client's state- ment refl ects ambivalence about the pregnancy, not her ability to care for the newborn. CN: Psychosocial adaptation; CL: Analyze

43. In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse: ■ 1. In 6 weeks when the episiotomy is com- pletely healed. ■ 2. After a postpartum check by the health care provider. ■ 3. Whenever the client is feeling amorous and desirable. ■ 4. When lochia fl ow and episiotomy pain have stopped.

43. 4. For most clients, sexual intercourse can be resumed when the lochia has stopped fl owing and epi- siotomy pain has ceased, usually about 3 weeks post- partum. Sexual intercourse may be painful until the episiotomy has healed. The client also needs instruc- tions about the possibility that pregnancy may occur before the return of the client's menstrual fl ow. The postpartum check by the health care provider typically occurs 4 to 6 weeks after delivery and most women have already had intercourse by this time. Typically, new mothers are exhausted and may not feel amorous or desirable for quite a while. In addition, the mother's physiologic responses may be diminished because of low hormonal levels, adjustments to the maternal role, and fatigue due to lack of rest and sleep. CN: Health promotion and maintenance; CL: Synthesize

43. After a vaginal delivery, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions? ■ 1. Left side, with the neck slightly fl exed. ■ 2. Back, with the head turned to the left side. ■ 3. Abdomen, with the head down. ■ 4. Back, with the neck slightly extended.

43. 4. When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the "sniffi ng" or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate's shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung expansion. Also, slightly fl exing the neck interferes with opening the airway. Placing the neonate on the back with the head turned to the left side does not allow for lung expansion. Placing the neonate on the abdomen interferes with proper positioning of the oxygen mask. CN: Pharmacological and parenteral therapies; CL: Synthesize

44. A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply. ■ 1. Interpretation of the fetal monitor strip. ■ 2. Analgesia or anesthesia being used. ■ 3. Anticipated method of birth control. ■ 4. Amount of vaginal bleeding or discharge. ■ 5. Support persons with the client. ■ 6. Prior delivery history.

44. 1, 2, 4, 5, 6. Knowledge of how the fetus is tolerating contractions as well as the frequency, intensity, and duration of contractions, as indicated on the fetal monitor strip, are extremely important. The type of analgesia or anesthesia being used, the client's response, and her pain rating should be included as well. The amount of vaginal bleeding indicates whether this labor is in the normal range. Vaginal discharge indicates if membranes are rup- tured and the color, odor, and amount of amniotic fl uid. The support persons with the client are an integral part of the labor process and greatly infl u- ence how she manages labor emotionally and, com- monly, physically. A complete change-of-shift report would include the client's name, age, gravida and parity, current and prior illnesses that may infl uence this hospitalization, prior labor and delivery his- tory if applicable, last vaginal examination time and fi ndings, vaginal bleeding, support persons with cli- ent, current I.V.s and other medications being used, and pertinent laboratory test results. Future plan for birth control would be the least important informa- tion to be given to the next shift because it will not impact the labor care plan. CN: Physiological adaptation; CL: Create

44. Which of the following actions should the nurse take when performing external cardiac mas- sage on a neonate born at 28 weeks' gestation? ■ 1. Alternate cardiac massage with ventilation. ■ 2. Compress the sternum with the palm of the hand. ■ 3. Compress the chest 70 to 80 times per minute. ■ 4. Displace the chest wall half the depth of the anterior-posterior diameter of the chest.

44. 1. Cardiac massage should be alternated with ventilation to ensure breathing and circulation. Two fi ngers, not the palm of the hand, are used to com- press a neonate's sternum. The chest is compressed 100 to 120 times per minute. The proper technique recommended by the American Heart Association and the American Academy of Pediatrics is to use enough pressure to depress the sternum to a depth of approximately one-third of the anterior-posterior diameter of the chest. CN: Physiological adaptation; CL: Apply

44. A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these fi ndings as suggesting that the client's husband is experiencing which of the following? ■ 1. Ptyalism. ■ 2. Mittelschmerz. ■ 3. Couvade syndrome. ■ 4. Pica.

44. 3. Couvade syndrome refers to the situation in which the expectant father experiences some of the discomforts of pregnancy along with the pregnant woman as a means of identifying with the pregnancy. Ptyalism is the term for excessive salivation. Mittelschmerz is the lower abdominal discomfort felt by some women during ovula- tion. Pica refers to an oral craving for substances such as clay or starch that some pregnant clients experience. CN: Psychosocial adaptation; CL: Analyze

44. The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous cli- ent after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication? ■ 1. Relief from episiotomy pain. ■ 2. Contraction of the uterus. ■ 3. Softening of the stool. ■ 4. Aid in sleeping.

44. 3. Docusate sodium (Colace) is a stool softener, used to assist in bowel elimination. The client is at risk for constipation because of decreased food and fl uid intake and pain from the episiotomy. Numerous analgesics, such as ibuprofen (Motrin) or acetamino- phen (Tylenol), could be used to treat episiotomy pain, helping the client achieve comfort and thus fall asleep. Oxytocin is used to contract the uterus. CN: Pharmacological and parenteral therapies; CL: Apply

44. The nurse is preparing to administer terb- utaline (Brethine) to a multigravid client in preterm labor. Before administering this drug intravenously, the nurse should determine the results of the following? ■ 1. Hematocrit. ■ 2. Weight gain. ■ 3. Urinary output. ■ 4. Heart rate.

44. 4. Tachycardia is a common adverse effect of terbutaline therapy. If the client's heart rate is 130 bpm or faster, the nurse should contact the phy- sician before administering the medication. After the drug has been administered, the client should also be carefully monitored for dyspnea or other symptoms of pulmonary edema. Other adverse effects include premature ventricular contractions, increased stroke volume, increased systolic pressure with decreased diastolic pressure, palpitations, tremors, nausea and vomiting, and shortness of breath. Other adverse effects include hyperglycemia, metabolic acidosis, hypokalemia, and anemia. Terbutaline has no known effects on the client's hemoglobin or hematocrit levels, or on weight. However, the drug can cause nausea. Terbutaline may result in perspiration, but there are no known effects on urinary output. CN: Pharmacological and parenteral therapies; CL: Synthesize

45. While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother's temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is fi rm, mid- line, and at the level of the umbilicus. The nurse should: ■ 1. Continue to monitor the client's vital signs. ■ 2. Assess the client's lochia for large clots. ■ 3. Notify the client's physician about the fi ndings. ■ 4. Offer the mother an ice pack for her forehead.

45. 1. The nurse needs to continue to monitor the client's vital signs. During the fi rst 24 hours post- partum it is normal for the mother to have a slight temperature elevation because of dehydration. A tem- perature of 100.4° F (38° C) that persists after the fi rst 24 hours may indicate an infection. Bradycardia during the fi rst week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client's respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client's vital signs are within normal limits and her fundus is fi rm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The physi- cian does not need to be notifi ed at this time. An ice pack is not necessary because the client's temperature is within normal limits. CN: Health promotion and maintenance; CL: Synthesize

45. A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following? ■ 1. Humidify the air being delivered. ■ 2. Cover the neonate's scalp with a warm cap. ■ 3. Record the neonate's temperature every 3 to 4 minutes. ■ 4. Assess the neonate's blood glucose level.

45. 1. Whenever oxygen is administered, it should be humidifi ed to prevent drying of the nasal passages and mucous membranes. Because the neonate is under a radiant warmer, a stocking cap is not necessary. Temperature, continuously monitored by a skin probe attached to the radiant warmer, is recorded every 30 to 60 minutes initially. Although the oxygen concentration in the hood requires close monitoring and measurement of blood gases, check- ing the blood glucose level is not necessary. CN: Pharmacological and parenteral therapies; CL: Apply

45. A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel move- ment. The nurse should fi rst: ■ 1. Have naloxone hydrochloride (Narcan) avail- able in the delivery room. ■ 2. Complete a vaginal examination to determine dilation, effacement, and station. ■ 3. Prepare for delivery. ■ 4. Document the client's relief due to pain medication.

45. 2. The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to delivery. The nurse should respond initially to the client's signs and symptoms by checking to validate current effacement, dilation, and station. If the fetus is ready to be delivered, having the room ready for the delivery and hav- ing naloxone hydrochloride (Narcan) available are important. Narcan completely or partially reverses the effects of natural and synthetic opioids, includ- ing respiratory depression. Documenting pain relief takes time away from the vaginal examination, pre- paring for delivery, and obtaining Narcan. The deliv- ery may be occurring rapidly. Being prepared for the delivery is a higher priority than documentation for this client. CN: Safety and infection control; CL: Synthesize

45. In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoan- terior (LOA) position? ■ 1. Near the symphysis pubis. ■ 2. Two inches above the umbilicus. ■ 3. Below the umbilicus on the left side. ■ 4. At the level of the umbilicus.

45. 3. As the uterus contracts, the abdominal wall rises and, when external monitoring is used, presses against the transducer. This movement is transmitted into an electrical current, which is then recorded. With the fetus in the LOA position, the cardiotransducer should be placed below the umbi- licus on the side where the fetal back is located and uterine displacement during contractions is greatest. If the fetal back is near the symphysis pubis, the fe- tus is presenting as a transverse lie. If the fetus is in a breech position, the fetal back may be at or above the umbilicus. CN: Reduction of risk potential; CL: Apply

45. A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which of the following would be the nurse's best response? ■ 1. "The effects of alcohol on a fetus during preg- nancy are unknown." ■ 2. "You should limit your consumption to beer and wine." ■ 3. "You should abstain from drinking alcoholic beverages." ■ 4. "You may have 1 drink or 2 oz of alcohol per day."

45. 3. Maternal alcohol use may result in fetal alcohol syndrome, marked by mild to moderate mental retardation, physical growth retardation, central nervous system disorders, and feeding dif- fi culties. Because there is no defi nitive answer as to how much alcohol can be safely consumed by a pregnant woman, it is recommended that pregnant clients be taught to abstain from drinking alcohol during pregnancy. Smoking and other medications also may affect the fetus. CN: Reduction of risk potential; CL: Apply

46. The physician orders betamethasone (Celestone) for a 34-year-old multigravid client at 32 weeks' gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks' gesta- tion. The nurse explains that this drug is given for which of the following reasons? ■ 1. To enhance fetal lung maturity. ■ 2. To counter the effects of tocolytic therapy. ■ 3. To treat chorioamnionitis. ■ 4. To decrease neonatal production of surfactant.

46. 1. Betamethasone therapy is indicated when the fetal lungs are immature. The fetus must be between 28 and 34 weeks' gestation and de- livery must be delayed for 24 to 48 hours for the drug to achieve a therapeutic effect. Antibiotics would be used to treat chorioamnionitis. Betame- thasone is not an antagonist for tocolytic therapy. It increases, not decreases, the production of neo- natal surfactant. CN: Pharmacological and parenteral therapies; CL: Apply

46. A multigravid laboring client has an exten- sive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The physician orders nalbuphine (Nubain) 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the delivery, which should the nurse avoid using with this client in this situation? ■ 1. 1% lidocaine (Xylocaine). ■ 2. Naloxone hydrochloride (Narcan). ■ 3. Local anesthetic. ■ 4. Pudendal block.

46. 2. Naloxone hydrochloride (Narcan) would not be used in a client who has a history of drug addiction. Narcan would abruptly withdraw this woman from the drug she is addicted to as well as the Nubain. The withdrawal would occur within a few minutes of injection and, if severe enough, could jeopardize the mother and fetus. Xylo- caine is a local anesthetic and numbs, rather than decreases the effects of Narcan. The local anesthetic and the pudendal block are both appropriate for this delivery but are used to numb the maternal perineum for delivery. CN: Pharmacological and parenteral therapies; CL: Synthesize

46. While assessing the episiotomy site of a primiparous client on the fi rst postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching? ■ 1. "I should try to gently manually replace the hemorrhoid." ■ 2. "Analgesic sprays and witch hazel pads can relieve the pain." ■ 3. "I should lie on my back as much as possible to relieve the pain." ■ 4. "I should drink lots of water and eat foods that have a lot of roughage."

46. 3. The client needs more teaching when she states, "I should lie on my back as much as possible to relieve the pain." Instead, the client should lie in the Sims position as much as possible to aid venous return to the rectal area and to reduce discomfort. Gentle manual replacement of the hemorrhoid is an appropriate measure to help relieve the discomfort and prevent enlargement. Analgesic sprays and witch hazel pads are helpful in reducing the dis- comfort of hemorrhoids. Drinking lots of water and eating roughage aid in bowel elimination, minimiz- ing the risk of straining and subsequent hemor- rhoidal development or enlargement. CN: Basic care and comfort; CL: Evaluate

46. Two hours ago, a neonate at 38 weeks' gesta- tion and weighing 3,175 g (7 lb) was born to a prim- iparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician? ■ 1. Alkalosis. ■ 2. Increased muscle tone. ■ 3. Temperature instability. ■ 4. Positive Babinski's refl ex.

46. 3. The neonate is at high risk for sepsis due to exposure to the mother's infection. Temperature instability in a neonate at 38 weeks' gestation is an early sign of sepsis. Other signs include tachycardia, decreased muscle tone, acidosis, apnea, respiratory distress, hypotension, poor feeding behaviors, vom- iting, and diarrhea. Late signs of infection include jaundice, seizures, enlarged liver and spleen, respi- ratory failure, and shock. Alkalosis is not typically seen in neonates who develop sepsis. Acidosis and respiratory distress may develop unless treatment such as antibiotics is started. A positive Babinski's refl ex is a normal fi nding and does not need to be reported. CN: Reduction of risk potential; CL: Analyze

46. Examination of a primigravid client com- plaining of increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these fi nd- ings as a response related to which of the following? ■ 1. A decrease in vaginal glycogen stores. ■ 2. Development of a sexually transmitted disease. ■ 3. Prevention of expulsion of the cervical mucus plug. ■ 4. Control of the growth of pathologic bacteria.

46. 4. An increase in clear, highly acidic vaginal secretions is a normal fi nding during pregnancy that aids in controlling the growth of pathologic bacteria. Vaginal secretions increase because of the infl u- ence of estrogen secretion and increased vaginal and cervical vascularity. The highly acidic nature of the vaginal secretions is caused by the action of Lactobacillus acidophilus, which increases the lactic acid content of the secretions. The increased acidity helps to make the vagina resistant to bacte- rial growth. During pregnancy, estrogen secretion fosters a glycogen-rich environment. Unfortunately, this glycogen-rich, acidic environment fosters the development of yeast (Candida albicans) infections, manifested by itching, burning, and a cheese-like vaginal discharge. If the client had a sexually trans- mitted disease, most likely she would complain of additional symptoms, such as lesions in the genital area or changes in color, consistency, or odor of the vaginal secretions. An increase in vaginal secretions does not help prevent expulsion of the mucus plug. The mucus plug is held in place by the cervix until the cervix becomes ripe. CN: Health promotion and maintenance; CL: Analyze

47. A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the fi rst hour after administration of the anesthetic, the nurse should monitor the client for: ■ 1. Hypotension. ■ 2. Diaphoresis. ■ 3. Headache. ■ 4. Tremors.

47. 1. When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vaso- dilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia. CN: Pharmacological and parenteral therapies; CL: Analyze

47. Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should fi rst: ■ 1. Consult with health care provider to obtain a chest x-ray. ■ 2. Reposition the neonate and then assess if the grunting and cyanosis resolve. ■ 3. Begin oxygen administration at 6-8 L via mask. ■ 4. Obtain a complete blood count to determine infection.

47. 1. With an absent apical pulse left of the mid- clavicular line accompanied by cyanosis, grunting, and diminished breath sounds, the neonate is most likely experiencing pneumothorax. Pneumothorax occurs when alveoli are over-distended and subse- quently the lung collapses, compressing the heart and lung and compromising the venous return to the right side of the heart. This condition can be confi rmed by X-ray or ultrasound studies. Repositioning the infant may open the airway, administering oxygen will improve oxygen saturation levels, and obtaining blood studies for infection will rule that out, but until pneumothorax is resolved, the other symptoms will continue. CN: Physiological adaptation; CL: Synthesize

47. When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the follow- ing points? ■ 1. Halfway between the client's symphysis pubis and umbilicus. ■ 2. At about the level of the client's umbilicus. ■ 3. Between the client's umbilicus and xiphoid process. ■ 4. Near the client's xiphoid process and com- pressing the diaphragm.

47. 2. Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a ges- tational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gesta- tion. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fun- dus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Ad- ditionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measure- ment near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older. CN: Health promotion and maintenance; CL: Apply

47. A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks little English. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which of the following? ■ 1. Foods from home are generally discouraged on the postpartum unit. ■ 2. The mother can bring the daughter any foods that she desires. ■ 3. This is permissible as long as the foods are nutritious and high in iron. ■ 4. The client's physician needs to give permis- sion for the foods.

47. 2. On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the physician's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In many Latino cultures, there is a belief in the "hot- cold" theory of disease; certain foods (hot) are pre- ferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the mother to bring her daughter "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship. CN: Basic care and comfort; CL: Synthesize

47. A client at 28 weeks' gestation in premature labor was placed on ritodrine (Yutopar). To main- tain the pregnancy, the physician orders the client to have 10 mg now, 10 mg in 2 hours, and then 20 mg every 4 hours while contractions persist, not to exceed the maximum daily oral dose of 120 mg. At what time will the client have reached the maxi- mum dose if she begins taking the medication at 10:00 a.m. and follows the physician's order? ___________________________ a.m.

47. 8:00 a.m. If 10 mg were administered at 10:00 a.m. and 12:00 p.m. and then 20 mg were administered at 4:00 p.m., 8:00 p.m., 10:00 p.m., 12:00 a.m., 4:00 a.m., and 8:00 a.m., the dose at 8:00 a.m. reached the maximum oral dose of 120 mg/day. CN: Pharmacological and parenteral therapies; CL: Apply

48. A primiparous client, 48 hours after a vagi- nal delivery, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following? ■ 1. Orange juice. ■ 2. Herbal tea. ■ 3. Milk. ■ 4. Grape juice.

48. 1. Iron is best absorbed in an acid environ- ment or with vitamin C. For maximum iron absorp- tion, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption. CN: Pharmacological and parenteral therapies; CL: Synthesize

51. The nurse instructs a primigravid client about the importance of suffi cient vitamin A in her diet. The nurse knows that the instructions have been effective when the client indicates that she should include which of the following in her diet? ■ 1. Buttermilk and cheese. ■ 2. Strawberries and cantaloupe. ■ 3. Egg yolks and squash. ■ 4. Oranges and tomatoes.

51. 3. Egg yolks and squash and other yellow vegetables are rich sources of vitamin A. Pregnant women should avoid megadoses of vitamin A because fetal malformations may occur. Buttermilk and cheese are good sources of calcium. Strawber- ries, cantaloupe, citrus fruits (such as oranges), and tomatoes are good sources of vitamin C, not vitamin A. CN: Basic care and comfort; CL: Evaluate

48. The nurse is caring for a multigravid cli- ent at 34 weeks' gestation diagnosed with preterm labor. The client has delivered two stillborn infants at 30 weeks' gestation. The client is scheduled for a sonogram before an amniocentesis. Which of the fol- lowing would be a priority nursing diagnosis for the client? ■ 1. Acute pain related to abnormal uterine con- tractions. ■ 2. Anxiety related to diagnostic tests for fetal well-being. ■ 3. Ineffective coping related to hospitalization. ■ 4. Defi cient knowledge related to consequences of preterm birth.

48. 2. For this client, who has experienced two stillbirths, the most appropriate diagnosis is Anxiety related to diagnostic tests for fetal well- being. With most antepartal diagnostic tests, pain is absent or minimal. Information to support the diagnoses of Ineffective coping or Defi cient knowl- edge is lacking. CN: Reduction of risk potential; CL: Analyze

48. Twenty-four hours after cesarean delivery, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explain- ing to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which of the following? ■ 1. Somatotropin. ■ 2. Surfactant. ■ 3. Testosterone. ■ 4. Progesterone.

48. 2. RDS, previously called hyaline membrane disease, is a developmental condition involving a decrease in lung surfactant leading to improper expansion of the lung alveoli. Surfactant contains a group of surface-active phospholipids, of which one component—lecithin—is the most critical for alveolar stability. Surfactant production peaks at about 35 weeks' gestation. This syndrome primarily attacks preterm neonates, although it can also affect term and post-term neonates. Altered somatotropin secretion is associated with growth disorders such as gigantism or dwarfi sm. Altered testosterone secretion is associated with masculinization. Altered progesterone secretion is associated with spontane- ous abortion during pregnancy. CN: Physiological adaptation; CL: Apply

48. A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of Hemophilia A in her family. The nurse informs the client that she will need to wait until she is 15 weeks gestation for the amniocente- sis. Which of the following provides the most appro- priate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? ■ 1. Fetal development needs to be complete before testing. ■ 2. The volume of amniotic fl uid needed for test- ing will be available by 15 weeks. ■ 3. Cells indicating Hemophilia A are not pro- duced until 15 weeks' gestation. ■ 4. Fetal anomalies are associated with amnio- centesis prior to 15 weeks' gestation.

48. 2. The volume of fl uid needed for amnio- centesis is 15 mL and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for Hemophilia A are available during the entire pregnancy but are not accessible by amnio- centesis until 12 weeks' gestation. Anomalies are not associated with amniocentesis testing. CN: Reduction of risk potential; CL: Apply

48. A 30-year-old G 3, P 2 is being monitored internally. She is being induced with I.V. oxytocin (Pitocin) because she is overdue. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. The nurse should first: *pic ■ 1. Continue to observe the fetal monitor. ■ 2. Anticipate rupture of the membranes. ■ 3. Prepare for fetal oximetry. ■ 4. Discontinue the Pitocin infusion.

48. 4. The fetal monitor strip shows late decel- erations. The fi rst intervention would be to turn off the Pitocin because the medication is causing the contractions. The stress caused by the contractions demonstrates that the fetus is not being perfused during the entire contraction (as shown by the late decelerations). There is no time to continue to observe in this situation; intervention is a priority. The client is attached to an internal fetal monitor, which would be possible only if her membranes had already ruptured. If the fetus continues to experi- ence stress, fetal oximetry may be initiated. CN: Physiological adaptation; CL: Analyze

49. When caring for a neonate born at 30 weeks' gestation who is in an isolette and receiving con- tinuous oxygen, which of the following would the nurse use as the best method to determine the effec- tiveness of this treatment? ■ 1. Evidence of cyanosis on mouth, hands, and feet. ■ 2. Continuous pulse rate monitoring. ■ 3. Arterial blood gas levels. ■ 4. Percentage of oxygen delivered.

49. 3. The best way to determine the adequacy of oxygen therapy is to monitor the neonate's arterial blood gas values. These results quantitatively mea- sure oxygen and carbon dioxide tensions. Cyanosis, a late sign, can validate laboratory fi ndings, but without laboratory results it is not a reliable indica- tor of the effectiveness of oxygen therapy. Likewise, pulse rate does not serve as a good index because there is poor correlation between it and extreme hyperoxia. The percentage of oxygen received is not a good indicator of the arterial blood gas level of oxygen. Even with high levels of oxygen, the preterm neonate may continue to have poor perfu- sion because of immature development of the heart and lungs. The percentage delivered is based on the analysis of the neonate's arterial blood gases. CN: Reduction of risk potential; CL: Evaluate

49. The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby's coming." After asking someone to call 911, the nurse assists the client to deliver a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breast-feeding, primarily for which of the following reasons? ■ 1. To begin the parental-infant bonding process. ■ 2. To prevent neonatal hypothermia. ■ 3. To provide glucose to the neonate. ■ 4. To contract the mother's uterus.

49. 4. After an emergency delivery, the nurse suggests that the mother begin breast-feeding to con- tract the uterus. Breast-feeding stimulates the natu- ral production of oxytocin. In a multiparous client, uterine atony is a potential complication because of the stretching of the uterine fi bers following each subsequent pregnancy. Although breast-feeding does help to begin the parental-infant bonding process, this is not the primary reason for the nurse to sug- gest breast-feeding. Prevention of neonatal hypo- thermia is accomplished by placing blankets on both the neonate and the mother. Although colostrum in breast milk provides the neonate with nutrients and immunoglobulins, the primary reason for breast- feeding is to stimulate the natural production of oxytocin to contract the uterus. CN: Reduction of risk potential; CL: Apply

49. After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which of the following? ■ 1. "A total weight gain of approximately 20 lb (9 kg) is recommended." ■ 2. "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." ■ 3. "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." ■ 4. "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

49. 4. The National Academy of Sciences In- stitute of Medicine recommends that women gain between 25 and 35 lb during pregnancy. These guidelines were developed to decrease the risk of intrauterine growth retardation. It is believed that the pattern of weight gain is as important as the total amount of weight gained. Underweight women and women carrying twins should have a greater weight gain. Typically, women should gain 3.5 lb during the fi rst trimester and then 1 lb/week dur- ing the remainder of the pregnancy (24 weeks) for a total of about 27 to 28 lb. A weight gain of only 6.6 lb in the second and third trimesters is not consid- ered normal because the client should be gaining about 1 lb/week, or 12 lb during the second and third trimesters. Gaining 12 lb during each trimester would total 36 lb, which is slightly more than the recommended weight gain. In addition, nausea and vomiting during the fi rst trimester can contribute to a lack of appetite and smaller weight gain during this trimester. CN: Health promotion and maintenance; CL: Evaluate

49. When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fl uid, the nurse would instruct the client that this test is done to evaluate the maturity of which of the following fetal systems? ■ 1. Urinary. ■ 2. Gastrointestinal. ■ 3. Cardiovascular. ■ 4. Pulmonary.

49. 4. The shake test helps determine the maturity of the fetal pulmonary system. The test is based on the fact that surfactant foams when mixed with ethanol. The more stable the foam, the more mature the fetal pulmonary system. Al- though the shake test is inexpensive and provides rapid results, problems have been noted with its reliability. Therefore, the lecithin-sphingomyelin ratio is usually determined in conjunction with the shake test. CN: Reduction of risk potential; CL: Apply

5. Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate? ■ 1. Take a mild analgesic if needed for menstrual pain. ■ 2. Avoid cold foods if menstrual pain persists. ■ 3. Stop exercise while menstruating. ■ 4. Avoid sexual intercourse while menstruating.

5. 1. The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or "cramps" are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases ab- dominal tone. Avoiding cold foods will not decrease dysmenorrhea. Sexual intercourse is not prohibited during menstruation, but the male partner should wear a condom to prevent exposure to blood.

5. A client delivered vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous and the client is complaining of pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? ■ 1. Begin sitz baths. ■ 2. Administer pain medication per order. ■ 3. Replace ice packs to the perineum. ■ 4. Initiate anesthetic sprays to the perineum.

5. 2. Pain medication is the fi rst strategy to initi- ate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the fi rst 24 hours and heat after the fi rst 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable. CN: Physiological adaptation; CL: Synthesize

5. At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia? ■ 1. Total weight gain. ■ 2. Short stature. ■ 3. Adolescent age group. ■ 4. Proteinuria.

5. 3. Clients with increased risk for preeclampsia include primigravid clients younger than 20 years or older than 40 years, clients with fi ve or more preg- nancies, women of color, women with multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total weight gain of 20 lb at 32 weeks' gestation with a 1-lb weight gain in the last 2 weeks is within normal limits. Short stature is not associated with the develop- ment of preeclampsia. A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+ or more may be a symptom of pregnancy-induced hypertension. CN: Reduction of risk potential; CL: Synthesize

5. A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V. for fl uid support. To increase safety prior to hanging new I.V. fl uids for a neonate, the nurse should: ■ 1. Check the neonate's weight. ■ 2. Determine if the neonate has adequate urine output. ■ 3. Determine the neonate's glucose level. ■ 4. Double-check the fl uids and physician's order with another nurse.

5. 4. Safe practice and error reduction can be increased by double-checking orders and medica- tions before administration. Knowing the neonate's weight, urinary output, and glucose level is an important part of understanding the potential needs of the neonate; however, double-checking orders and interventions is the most important step to increase safety. CN: Safety and infection control; CL: Synthesize

50. When developing a teaching plan for a client who is 8 weeks pregnant, which of the following foods would the nurse suggest to meet the client's need for increased folic acid? ■ 1. Spinach. ■ 2. Bananas. ■ 3. Seafood. ■ 4. Yogurt.

50. 1. Green, leafy vegetables, such as aspara- gus, spinach, brussel sprouts, and broccoli, are rich sources of folic acid. The pregnant woman needs to eat foods high in folic acid to prevent folic acid defi cits, which may result in neural tube defects in the newborn. A well-balanced diet must include whole grains, dairy products, and fresh fruits; however, bananas are rich in potassium, seafood is rich in iodine, and yogurt is rich in cal- cium, not folic acid. CN: Reduction of risk potential; CL: Apply

50. A viable male neonate delivered to a 28-year-old multiparous client by cesarean deliv- ery because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? ■ 1. Mother's development of placenta previa. ■ 2. Neonate delivered preterm. ■ 3. Mother receiving analgesia 4 hours before delivery. ■ 4. Neonate with sluggish respiratory efforts after delivery.

50. 2. RDS is a developmental condition that primarily affects preterm infants before 35 weeks' gestation because of inadequate lung development from defi cient surfactant production. The develop- ment of placenta previa has little correlation with the development of RDS. Although excessive analge- sia can depress the neonate's respiratory condition if it is given shortly before birth, the scenario presents no information that this has occurred. The neonate's sluggish respiratory activity postpartum is not the likely cause of RDS but may be a sign that the neo- nate has the condition. CN: Reduction of risk potential; CL: Synthesize

50. Approximately 15 minutes after delivery of a viable term neonate, a multiparous client complains of a chill. Which of the following should the nurse do next? ■ 1. Assess the client's pulse rate. ■ 2. Decrease the rate of intravenous fl uids. ■ 3. Provide the client with a warm blanket. ■ 4. Assess the amount of blood loss.

50. 3. A chill shortly after delivery is a com- mon, normal occurrence. Warm blankets can help provide comfort for the client. It has been suggested that the shivering response is caused by a difference between internal and external body temperatures. A different theory proposes that the woman is reacting to fetal cells that have entered the maternal bloodstream through the placental site. Assess- ing the client's pulse rate will provide no further information about the chill. Decreasing the I.V. rate will not infl uence the length of time the client trembles. Assessing blood loss is a standard of care at this point postpartum but has no correlation to the chill. CN: Health promotion and maintenance; CL: Synthesize

50. The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confi rmed rupture of membranes and no evidence of labor. Which of the following would the nurse expect the physician to order? ■ 1. Frequent assessments of cervical dilation. ■ 2. Intravenous oxytocin administration. ■ 3. Vaginal culture for Neisseria gonorrhoeae. ■ 4. Sonogram for amniotic fl uid volume index.

50. 3. Because an intrauterine infection may occur when membranes have ruptured, vaginal cultures for N. gonorrhoeae, group B streptococ- cus, and chlamydia are usually taken. Prophylactic antibiotics may be prescribed to reduce the risk of infection in the newborn. Frequent vaginal exami- nations should be avoided because they can further increase the client's risk for infection. Intravenous oxytocin to initiate labor may be used if an infec- tion occurs. Bed rest can sometimes prolong the pregnancy and prevent a preterm birth. A sono- gram may be used to validate rupture of the mem- branes with an amniotic fl uid index. However, it is not needed if the physician has confi rmed the rupture. CN: Reduction of risk potential; CL: Apply

50. The nurse is caring for a multiparous client after vaginal delivery of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to: ■ 1. Bottle-feed the twins to prevent exhaustion and fatigue. ■ 2. Plan for each parent to spend equal amounts of time with each twin. ■ 3. Avoid assistance from other family members until attachment occurs. ■ 4. Relate to each twin individually to enhance the attachment process.

50. 4. It is believed that the process of attachment is structured so that the parents become attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to each twin individu- ally, rather than as a unit, to enhance the attachment process. Mothers of twins are usually able to breast- feed successfully because the milk supply increases on demand. However, possible fatigue and exhaus- tion require that the mother rest whenever possible. It would be highly unlikely and unrealistic that each parent would be able to spend equal amounts of time with both twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage assistance from family and friends, because caring for twins or other multiple births (e.g., triplets) can be exhausting for the family. CN: Psychosocial adaptation; CL: Synthesize

51. The physician plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, the nurse should first: ■ 1. Monitor the client's contraction pattern. ■ 2. Assess the fetal heart rate (FHR) for 1 full minute. ■ 3. Assess the client's temperature and pulse. ■ 4. Document the color of the amniotic fluid.

51. 2. After an amniotomy, the nurse should plan to fi rst assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the physician. A cord prolapse requires prompt delivery by cesar- ean section. The client's contraction pattern should be monitored once labor has been established. The client's temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fl uid, but this can be done after the FHR is assessed and a reassuring pattern is present. CN: Health promotion and maintenance; CL: Synthesize

51. Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and fi nds it to be fi rm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next? ■ 1. Document this as a normal fi nding in the cli- ent's record. ■ 2. Contact the physician for an order for methyl- ergonovine. ■ 3. Encourage the client to ambulate to the bath- room and void. ■ 4. Gently massage the fundus to expel the clots.

51. 3. At 12 hours postpartum, the fundus nor- mally should be in the midline and at the level of the umbilicus. When the fundus is fi rm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involu- tion. A fi rm but deviated fundus above the level of the umbilicus is not a normal fi nding and if voiding does not return it to midline, it should be reported to the physician. Methylergonovine (Methergine) is used to treat uterine atony. This client's fundus is fi rm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots. CN: Reduction of risk potential; CL: Synthesize

51. A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fl uid with nitrazine paper, the nurse confi rms that the client's membranes have ruptured when the paper turns which of the following colors? ■ 1. Yellow. ■ 2. Green. ■ 3. Blue. ■ 4. Red.

51. 3. If the client's membranes have ruptured, the nitrazine paper will turn blue, an alkaline reac- tion. False positives may occur when the nitrazine paper is exposed to blood or semen. The defi nitive test for rupture of membranes is fern testing, where amniotic fl uid is allowed to dry on a slide and then viewed under a microscope. Dried amniotic fl uid will form a fern pattern. No other fl uid forms this type of pattern. CN: Reduction of risk potential; CL: Analyze

51. While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidifi ed. The nurse should tell the mother? ■ 1. "The humidity promotes expansion of the neonate's immature lungs." ■ 2. "The humidity helps to prevent viral or bacte- rial pneumonia." ■ 3. "Oxygen is drying to the mucous membranes unless it is humidifi ed." ■ 4. "Circulation to the baby's heart is improved with humidifi ed oxygen."

51. 3. Oxygen should be humidifi ed before admin- istration to help prevent drying of the mucous mem- branes in the respiratory tract. Drying impedes the normal functioning of cilia in the respiratory tract and predisposes to mucous membrane irritation. Humidi- fi cation of oxygen does not promote expansion of the immature lungs. Expansion is promoted by placing the infant in a prone position or providing the pre- term infant with surfactant medication. Humidifi ed oxygen does not prevent viral or bacterial pneumonia. In fact, in some nurseries, Staphylococcus aureus has been detected in moist environments and on the hands and nails of staff members, predisposing the neonate to pneumonia. Humidifi ed oxygen does not improve blood circulation in the cardiac system. CN: Pharmacological and parenteral therapies; CL: Apply

52. The nurse is discussing dietary concerns with pregnant teens. Which of the following choices are convenient for teens yet nutritious for both the mother and fetus? Select all that apply. ■ 1. Milkshake or yogurt with fresh fruit or gra- nola bar. ■ 2. Chicken nuggets with tater tots. ■ 3. Cheese pizza with spinach and mushroom topping. ■ 4. Peanut butter with crackers and a juice drink. ■ 5. Buttery light popcorn with diet cola. ■ 6. Cheeseburger with tomato, lettuce, pickle, ketchup, and baked potato.

52. 1, 3, 4. Dairy products, fresh fruit, vegetables, and foods high in protein (like cheese and peanut butter) are excellent choices. Fried foods, such as chicken nuggets and tater tots, and foods such as cheeseburgers and buttered popcorn are high in fat; carbonated drinks such as diet colas, and foods such as pickles and ketchup contain large amounts of sodium. These foods can lead to an increase in ankle edema and promote weight gain from empty calories. CN: Health promotion and maintenance; CL: Apply

52. A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge? Select all that apply. ■ 1. "I know to wait 2 weeks before I start my birth control pills." ■ 2. "I have the hospital phone number if I have any questions." ■ 3. "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medi- cal assistance." ■ 4. "My mother is coming to help for a month so I will be fi ne." ■ 5. "I know if I get fever or chills or change in lochia to call the physician." ■ 6. "I will continue my prenatal vitamins until my postpartum checkup or longer."

52. 2, 3, 5, 6. The nurse is responsible for provid- ing discharge instructions that include signs and symptoms that need to be reported to the physician as well as resources and follow-up for home care if needed. Phone numbers and health practices to promote healing, such as the use of prenatal vitamins, are also essential pieces of information. The use of birth control pills needs to be discussed with the phy- sician. A progesterone-only pill is used if the client is breast-feeding. Oral contraceptives should be initiated according to the physician's advice. Although the client's mother may be helpful, the client's statement that she will be fi ne because her mother is coming indicates that she is unaware or ignoring information about valuable information and resources. CN: Reduction of risk potential; CL: Evaluate

52. Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic? ■ 1. Pain related to episiotomy and exhaustive pushing efforts. ■ 2. Anxiety related to inability to move legs and toes. ■ 3. Risk for injury related to epidural anesthesia. ■ 4. Excess fluid volume overload related to labor process and intravenous fluids.

52. 3. The most appropriate diagnosis at this time is Risk for injury related to the effects of the epidural anesthesia because the client may have no sensation in her lower abdomen and legs for several hours postpartum. Care should be taken to avoid injury, and ambulation should be delayed until sen- sation has returned. No information is presented in the scenario to suggest Pain due to episiotomy and exhaustive pushing. Multiparous clients commonly have shortened labors and may not require an epi- siotomy. If the client did have an episiotomy and the epidural anesthetic has worn off, then this nursing diagnosis would be appropriate. Anxiety would apply if the client expressed feelings of anxiety or nervousness because of a problem with moving her legs or toes. Excess fl uid volume would apply if the client received excessive amounts of intravenous fl uid or complained of oliguria, an early sign of pul- monary edema. CN: Pharmacological and parenteral therapies; CL: Analyze

52. A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate? ■ 1. Breast-feeding is not recommended because the neonate needs increased fat in the diet. ■ 2. Once the neonate no longer needs oxygen and continuous monitoring, breast-feeding can be done. ■ 3. Breast-feeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. ■ 4. Gavage feedings using breast milk can be given until the neonate can coordinate suck- ing and swallowing.

52. 4. Many intensive care units that care for high- risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow refl ex, breast-feeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escheri- chia coli and Shigella species. Some studies have also shown that breast-fed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotiz- ing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortifi ed with an additive to provide addi- tional calories. Neonates who are receiving oxygen can breast-feed. During feedings, supplemental oxygen can be delivered by nasal cannula. CN: Health promotion and maintenance; CL: Apply

55. Which of the following subjects should the nurse include when teaching the mother of a neo- nate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications? ■ 1. Laser therapy. ■ 2. Cromolyn sodium (Intal) eye drops. ■ 3. Frequent testing for glaucoma. ■ 4. Corneal transplants.

55. 1. Because the retina may become detached with ROP, laser therapy has been used successfully in some medical centers to treat ROP. Cromolyn sodium (Intal) is used to treat seasonal allergies. ROP is not associated with glaucoma, so frequent testing is not necessary. Because the vessels of the eye are affected, not the corneas, corneal transplan- tation is not used. CN: Physiological adaptation; CL: Apply

52. A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's: ■ 1. Red blood cell count. ■ 2. Degree of discomfort. ■ 3. Urinary output. ■ 4. Temperature.

52. 4. Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide informa- tion related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis. CN: Reduction of risk potential; CL: Analyze

53. A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests posi- tive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; tempera- ture, 100° F (37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the physician to order? ■ 1. Intravenous penicillin. ■ 2. Intravenous gentamicin sulfate (Garamycin). ■ 3. Intramuscular betamethasone (Celestone). ■ 4. Intramuscular cefaclor (Ceclor).

53. 1. Because group B streptococcus is a gram- positive bacteria, the physician probably will order intravenous penicillin to treat the mother's infection and prevent fetal infection. Gentamicin sulfate, which acts on gram-negative bacteria, would be inappropriate. Administering a corticos- teroid, such as betamethasone, is inappropriate because the premature rupture of the membranes enhances fetal lung maturity. The lack of amniotic fl uid causes early maturation of lung tissue. Cefaclor, which is available only in the oral form, is used for upper and lower respiratory tract infec- tions and urinary tract infections by gram-negative staphylococci. CN: Pharmacological and parenteral therapies; CL: Analyze

53. Which of the following would the nurse expect as a common fi nding for a multiparous client delivering a viable neonate at 41 weeks' gestation with the aid of a vacuum extractor? ■ 1. Caput succedaneum. ■ 2. Cephalohematoma. ■ 3. Maternal lacerations. ■ 4. Neonatal intracranial hemorrhage.

53. 1. Caput succedaneum is common after the use of a vacuum extractor to assist the client's expul- sion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalo- hematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps deliveries, but it is not a com- mon fi nding. CN: Health promotion and maintenance; CL: Analyze

53. An antenatal client is discussing her anemia with the nurse in the prenatal clinic. After a discus- sion about sources of iron to be incorporated into her daily meals, the nurse knows the client needs further instruction when she responds with which of the following? ■ 1. "I can meet two goals when I drink milk, lots of iron and meeting my calcium needs at the same time." ■ 2. "Drinking coffee, tea, and sodas decrease the absorption of iron." ■ 3. "I can increase the absorption of iron by drinking orange juice when I eat." ■ 4. Cream of wheat and molasses are excellent sources of iron."

53. 1. Milk contains a large amount of calcium but contains no iron. Coffee, tea, and caffeinated soft drinks inhibit the absorption of iron. The vitamin C found in orange juice enhances the absorption of iron. Cream of wheat (1 cup/10 mg iron) and molasses (1 tbsp/3.0 mg iron) are considered excel- lent sources of iron as they contain the indicated amounts of iron. CN: Physiological adaptation; CL: Evaluate

53. Which of the following best identifi es the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)? ■ 1. The neonate is at risk because of multiple factors. ■ 2. Oxygen is being administered at a level of 21%. ■ 3. The neonate was alkalotic immediately after birth. ■ 4. Phototherapy is likely to be ordered by the pediatrician.

53. 1. ROP, previously called retrolental fi broplasia, is associated with multiple risk factors, including high arterial blood oxygen levels, prematurity, and very low birth weight (less than 1,500 g). In the early acute stages of ROP, the neonate's immature retinal vessels con- strict. If vasoconstriction is sustained, vascular closure follows, and irreversible capillary endothelial damage occurs. Normal room air is at 21%. Acidosis, not alka- losis, is commonly seen in preterm neonates, but this is not related to the development of ROP. Phototherapy is not related to the development of ROP. However, during phototherapy, the neonate's eyes should be con- stantly covered to prevent damage from the lights. CN: Reduction of risk potential; CL: Apply

The Postpartal Client Who Breast-Feeds 53. The nurse is reviewing discharge instructions with a postpartum breast-feeding client who is going home. She has chosen medroxyprogesterone (Depo- Provera) as birth control. Which statement by the client identifi es that she needs further instruction concerning birth control? ■ 1. "I will wait for my 6-week check up to get my fi rst Depo-Provera shot." ■ 2. "Depo-Provera injections last for 90 days." ■ 3. "My milk supply should be well established before using Depo-Provera." ■ 4. "You will give me my fi rst Depo-Provera shot before I leave today."

53. 4. Depo-Provera is a progestin contracep- tive that can reduce the initial production of breast milk. It is given to a breast-feeding woman when she returns for the 6-week postpartum check up. By this time, the milk supply is well established and will remain at that level. Depo-Provera is effec- tive as a contraceptive for 90 days. Clients who are bottle-feeding may be given Depo-Provera prior to discharge from the hospital. CN: Pharmacological and parenteral therapies; CL: Evaluate

54. The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation? pic ■ 1. Frank breech. ■ 2. Complete breech. ■ 3. Footling breech. ■ 4. Vertex.

54. 1. Breech presentations account for 5% of all births and the most common is frank breech. In frank breech, there is fl exion of the fetal thighs and exten- sion of the knees. The feet rest at the side of the fetal head. In complete breech, there is fl exion of the fetal thighs and knees; the fetus appears to be squatting. Footling breech occurs when there is an extension of the fetal knees and one or both feet protrude through the cervix. Vertex presentation occurs in 95% of deliveries with the head is engaged in the pelvis. CN: Physiological adaptation; CL: Apply

54. The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which of the following? ■ 1. Prevention of demineralization of the moth- er's bones. ■ 2. Synthesis of proteins, nucleic acids, and fats. ■ 3. Amino acid metabolism. ■ 4. Synthesis of neural pathways in the fetus.

54. 2. Magnesium aids in the synthesis of pro- tein, nucleic acids, proteins, and fats. It is impor- tant for cell growth and neuromuscular function. Magnesium also activates the enzymes for me- tabolism of protein and energy. Calcium prevents demineralization of the mother's bones. Vitamin B6 is important for amino acid metabolism. Folic acid assists in the development of neural pathways in the fetus. CN: Basic care and comfort; CL: Apply

54. A postpartum primiparous client is hav- ing diffi culty breast-feeding her infant. The infant latches on to the breast but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breast-feeding when she states: ■ 1. "The baby needs to have as much of the nipple and areola in his mouth as possible to prevent sore and cracked nipples." ■ 2. "I can put breast milk on my nipples to heal the sore areas." ■ 3. "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." ■ 4. "Feeding the baby for a half-hour on each side will not make my breasts sore. "

54. 3. As much of the mother's nipple and areola need to be in the infant's mouth in order to establish a latch that does not cause nipple cracks or fi ssures. Having the nipple and the areola deep in the infant's mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking and fi ssures. Breast milk has been found to heal nipples when placed on the nipple at the completion of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant's mouth. CN: Health promotion and maintenance; CL: Evaluate

54. A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the home health nurse. After instruction about care while at home, which of the following client state- ments indicates effective teaching? ■ 1. "It is permissible to douche if the fl uid irri- tates my vaginal area." ■ 2. "I can take either a tub bath or a shower when I feel like it." ■ 3. "I should limit my fl uid intake to less than 1 quart daily." ■ 4. "I should contact the doctor if my tempera- ture is 100.4° F or higher."

54. 4. Because of the client's increased risk for infection, successful teaching is indicated when the client states that she will contact the doctor if her temperature is 100.4° F (38° C) or greater. The client should be instructed to monitor her temperature twice daily. The client should refrain from coitus, douching, and tub bathing, which can increase the potential for infection. Showering is permitted be- cause water in the shower doesn't enter the vagina and increase the risk of infection. A fl uid intake of at least 2 L daily is recommended to prevent poten- tial urinary tract infection. CN: Reduction of risk potential; CL: Evaluate

54. Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g? ■ 1. Sunken orbital sockets. ■ 2. Strabismus. ■ 3. Reaction to bright light. ■ 4. Constricted retinal vessels.

54. 4. Constricted retinal vessels may indicate the degree of ROP. In ROP, immature blood vessels in the retina constrict and become permanently occluded. New vessels proliferate to reestablish cir- culation. If the new vessels extend into the vitreous humor of the eye, hemorrhage can occur, resulting in scarring and retinal detachment. Sunken orbital sockets would be suggestive of dehydration, not ROP. Strabismus ("crossed eyes") is common in all neonates because of poor oculomotor coordination. A reaction to bright light is a normal fi nding. CN: Reduction of risk potential; CL: Analyze

55. The nurse is caring for a primipara who delivered her baby yesterday and has chosen to breast-feed her neonate. Which assessment fi nding is considered unusual for the client at this point postpartum? ■ 1. Milk production. ■ 2. Diaphoresis. ■ 3. Constipation. ■ 4. Diuresis.

55. 1. New mothers usually begin to produce milk at about the third day postpartum and colos- trum is produced until that time. For clients who have breast-fed another infant during pregnancy, having milk shortly after delivery is not unusual. Diaphoresis and diuresis are considered normal during this time as the body excretes the additional fl uids that are no longer needed after the pregnancy. Constipation may continue for several days as a result of progesterone remaining in the system, the consummation of iron, and trauma to the perineum. CN: Physiological adaptation; CL: Analyze

55. When caring for a primigravid client at 9 weeks' gestation who immigrated to the United States from Vietnam 1 year ago, the nurse would assess the client's diet for a defi ciency of which of the following? ■ 1. Calcium. ■ 2. Vitamin E. ■ 3. Vitamin C. ■ 4. Iodine.

55. 1. The diet for Vietnamese Americans typi- cally consists of small portions of meat and ample amounts of rice. Fresh milk may not have been readily available in Vietnam, and many Asian clients are lactose intolerant. Therefore, the nurse would need to assess the client's diet for defi cien- cies of calcium and possibly iron. Traditionally, Southeast Asian diets have an abundance of dark green leafy vegetables, such as mustard greens and bok choy, which contain adequate amounts of vitamin E and vitamin C. Seafood, which contains iodine, is usually adequate in the diets of Southeast Asian women. CN: Reduction of risk potential; CL: Analyze

55. A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do fi rst? ■ 1. Check the status of the fetal heart rate. ■ 2. Turn the client to her right side. ■ 3. Test the leaking fl uid with nitrazine paper. ■ 4. Perform a sterile vaginal examination.

55. 1. The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse's fi rst action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or in- creased pressure on the fetal umbilical cord inhibit- ing fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to her right side is not necessary. If the cord does prolapse, the client should be placed in a knee- to-chest or Trendelenburg position. Checking the fl uid with nitrazine paper and vaginal examination are appropriate once the status of the fetus has been evaluated. CN: Reduction of risk potential; CL: Synthesize

55. Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 sta- tion. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: ■ 1. Warm the temperature of the room by a few degrees. ■ 2. Increase the rate of intravenous fluid adminis- tration. ■ 3. Obtain an order for an intramuscular anti- emetic medication. ■ 4. Assess the client's cervical dilation and station.

55. 4. The nurse should assess the client's cervical dilation and station, because the client's symptoms are indicative of the transition phase of labor. Multiparous clients can proceed 5 to 9 cm per hour during the active phase of labor. Warming the temperature of the room is not helpful because the client will soon be ready to begin expulsive pushing. Increasing the intravenous fl uid rate is not warranted unless the client is experiencing dehydra- tion. Administration of an antiemetic at this point in labor is not warranted and may result in neonatal depression should a rapid delivery occur. CN: Health promotion and maintenance; CL: Synthesize

56. Three days after admission of a neonate delivered at 30 weeks' gestation, the neonatologist plans to assess the neonate for periventricular- intraventricular hemorrhage (PIVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following? ■ 1. Computed tomography scan. ■ 2. Arterial blood specimen collection. ■ 3. Radiographs of the skull. ■ 4. Complete blood count specimen collection.

56. 1. Neonates who weigh less than 1,500 g or are born at less than 34 weeks' gestation are sus- ceptible to PIVH. Computed tomography scanning or ultrasound scanning can confirm the diagnosis. The spinal fl uid will show an increased number of red blood cells. Arterial blood gas specimen collection is done to evaluate the neonate's oxygen saturation level. Skull radiographs are not commonly used because of the danger of radiation. Additionally, computed tomography scans have replaced the use of skull X-ray fi lms because they can provide more defi nitive results. Complete blood count specimen collection is usually per- formed to determine the hemoglobin, hematocrit, and white blood cell count. The results are not specifi c for PIVH. CN: Reduction of risk potential; CL: Apply

56. The nurse is caring for several mother-baby couplets. In planning the care for each of the cou- plets, which mother would the nurse expect to have the most severe afterbirth pains? ■ 1. G 4, P 1 client who is breast-feeding her infant. ■ 2. G 3, P 3 client who is breast-feeding her infant. ■ 3. G 2, P 2 cesarean client who is bottle-feeding her infant. ■ 4. G 3, P 3 client who is bottle-feeding her infant.

56. 2. The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus fi lled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain. CN: Physiological adaptation; CL: Evaluate

56. Which of the following statements by a prim- igravid client scheduled for chorionic villi sampling indicates effective teaching about the procedure? ■ 1. "A fi beroptic fetoscope will be inserted through a small incision into my uterus." ■ 2. "I can't have anything to eat or drink after midnight on the day of the procedure." ■ 3. "The procedure involves the insertion of a thin catheter into my uterus." ■ 4. "I need to drink 32 to 40 oz of fl uid 1 to 2 hours before the procedure."

56. 3. Chorionic villi sampling, which can be performed between 8 and 10 weeks' gestation, involves the insertion of a thin catheter into the vagina and uterus to obtain a sample of the chori- onic cells. It is a useful diagnostic test to determine trisomy 13, translocations, fragile X syndrome, and trisomy 18. Fetoscopy is performed with a small fi - beroptic fetoscope inserted through a small incision into the client's uterus to inspect the fetus for gross abnormalities. There are no food or fl uid restric- tions necessary before chorionic villi sampling. Ideally, the client should empty the bladder before this procedure. A full bladder would be needed if the client were scheduled to have an ultrasound examination. CN: Reduction of risk potential; CL: Evaluate

56. A client with gestational diabetes who is entering her third trimester is learning how to moni- tor her fetus's movements. After teaching the cli- ent about the kick count, the nurse should provide further instruction if the client makes which of the following statements? ■ 1. "The baby may be more active at different times of the day." ■ 2. "How I feel my baby move is different than my friend." ■ 3. "The baby should be moving less than 10 times in 3 hours." ■ 4. "The baby may not move at times because it is asleep."

56. 3. Feeling four kicks in 30 minutes or feeling 10 or more kicks in 3 hours are norms. Fetuses are more active at various times of the day particularly after a mother has eaten (when the blood glucose level is high) and in the evening. Each individual perceives their fetus to move differently. Fetuses do sleep several times per day for about 30 minutes each time. CN: Safety and infection control; CL: Evaluate

56. When assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area, the nurse should assess the inter- val between which of the following? ■ 1. Acme of one contraction to the beginning of the next contraction. ■ 2. Beginning of one contraction to the end of the next contraction. ■ 3. End of one contraction to the end of the next contraction. ■ 4. Beginning of one contraction to the beginning of the next contraction.

56. 4. To assess the frequency of the client's con- tractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifi es the peak of a contraction. CN: Health promotion and maintenance; CL: Analyze

57. A breast-feeding client is seen at home by the visiting nurse 10 days after a vaginal delivery. The client is complaining of a warm, red, painful breast; a temperature of 100° F; and fl ulike symptoms. What should the nurse do? ■ 1. Encourage the client to breast-feed her infant using the unaffected breast. ■ 2. Refer the woman to her primary health care provider. ■ 3. Inform the client that she needs to discon- tinue breast-feeding. ■ 4. Instruct the woman to apply warm com- presses to the affected breast.

57. 2. The client is exhibiting signs and symptoms of a breast infection (mastitis). The nurse should instruct her to contact her health care provider, who will likely order a prescription for antibiotics. She should continue to breast-feed the infant from both breasts. Frequent breast-feeding is encouraged rather than discontinuing the process for anyone having a breast infection. Applying warm compresses may relieve pain. However, the underlying infection indicated by the elevated temperature indicates that additional treatment with antibiotics will be needed. CN: Management of care; CL: Synthesize

57. While a client is being admitted to the birth- ing unit she states, "My water broke last night, but my labor started two hours ago." Which of the fol- lowing is a concern? Select all that apply. ■ 1. Maternal vital signs: T. 99.5, HR 80, R 24, BP 130/80 mm Hg. ■ 2. Blood and mucus on perineal pad. ■ 3. Baseline fetal heart rate of 140 with a range between 110 and 160 with contractions. ■ 4. Peripad stained with green fl uid. ■ 5. The client states, "This baby wants out—he keeps kicking me."

57. 3, 4, 5. The range of fetal heart rate fl uctuat- ing too high and low could indicate fetal distress. The green peripad fl uid indicates meconium, which could be associated with fetal distress. Increased fetal activity during labor may also indicate distress. The maternal vital signs noted and a perineal pad with blood and mucus are normal fi ndings. CN: Reduction of risk potential; CL: Analyze

57. Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? ■ 1. Increased muscle tone. ■ 2. Hyperbilirubinemia. ■ 3. Bulging fontanels. ■ 4. Hyperactivity.

57. 3. A common fi nding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia con- tribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystag- mus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyper- bilirubinemia refers to an increase in bilirubin in the blood and is not associated with IVH. CN: Physiological adaptation; CL: Analyze

57. A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. The nurse interprets this as which of the following? ■ 1. The possibility that the client is carrying twins. ■ 2. Unusual because most multiparous clients do not experience quickening until 30 weeks' gestation. ■ 3. Evidence that the client's estimated date of delivery is probably off by a few weeks. ■ 4. Normal because multiparous clients can expe- rience quickening between 14 and 20 weeks'

57. 4. Although most multiparous women expe- rience quickening at about 171⁄2 weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect. Detecting move- ment early does not suggest a twin pregnancy. If the multiparous client does not experience quick- ening by 20 weeks' gestation, further investigation is warranted, because the fetus may have died, the client has a hydatidiform mole, or the pregnancy dating is incorrect. There is no evidence that the client's expected date of delivery is erroneous. CN: Health promotion and maintenance; CL: Analyze

62. Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' ges- tation who is currently in an isolette with humidi- fi ed oxygen and receiving intravenous fl uids has developed overhydration? ■ 1. Hypernatremia. ■ 2. Polycythemia. ■ 3. Hypoproteinemia. ■ 4. Increased urine specifi c gravity.

62. 3. Decreased protein or hypoproteinemia is a sign of overhydration, which can lead to patent ductus arteriosus or congestive heart failure. Bulging fontanels, decreased serum sodium, decreased urine specifi c gravity, and decreased hematocrit are other signs of overhydration. Hypernatremia (increased serum sodium concentration) or increased urine specifi c gravity would suggest dehydration, not overhydration. Polycythemia evidenced by an elevated hematocrit would suggest hypoxia or congenital heart disorder. CN: Reduction of risk potential; CL: Analyze

57. A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. The nurse should tell the client that the test results indicate which of the fol- lowing? ■ 1. A contraction stress test is necessary. ■ 2. The nonstress test should be repeated. ■ 3. Chorionic villus sampling is necessary. ■ 4. There is evidence of fetal well-being.

57. 4. The nonstress test is considered reactive when two or more fetal heart rate accelerations of at least 15 bpm occur (from a baseline fetal heart rate of 120 to 160 bpm), along with fetal movement, during a 10- to 20-minute period. A reactive non- stress test indicates fetal heart rate accelerations and well-being. There is no indication for further evalu- ation (such as a contraction stress test). However, contraction stress tests are commonly scheduled for pregnant clients with insulin-dependent diabetes in the latter part of pregnancy and are repeated peri- odically until delivery. Chorionic villus sampling is usually performed early in the pregnancy to detect fetal abnormalities. CN: Reduction of risk potential; CL: Synthesize

58. An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifi er in the infant's mouth during these feedings. The nurse replies that the pacifi er helps in what ways? Select all that apply. ■ 1. Teaches the infant to suck and swallow. ■ 2. Provides oral stimulation. ■ 3. Keeps oral mucus membranes moist while the tube is in place. ■ 4. Reminds the infant how to suck. ■ 5. Stimulates secretions that help gastric emptying.

58. 2, 4, 5. Nonnutritive sucking has been seen in infants as early as 28 weeks and ultrasound examina- tions have shown thumb sucking in utero even ear- lier. Nonnutritive sucking provides oral stimulation and allows the baby to maintain the sucking refl ex needed for breast- or bottle-feedings later. It does not teach the infant how to suck and swallow. Sucking is thought to help with gastric emptying by stimulat- ing secretions of GI peptides. Moisture of the mucus membranes is an indication of adequate hydration, and nonnutritive sucking will not have an effect. CN: Basic care and comfort; CL: Apply

58. A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following? ■ 1. Frequent late decelerations. ■ 2. Decreased fetal movement. ■ 3. Inconsistent late decelerations. ■ 4. Lack of fetal movement.

58. 3. A contraction stress test is used to evalu- ate fetal well-being during a simulated labor. A suspicious contraction stress test indicates inconsistent late deceleration patterns requiring further evaluation. A negative contraction stress test indicates no late decelerations and is the desired outcome. A positive contraction stress test indicates fetal compromise with frequent late decelerations. Fetal movements are one of the pa- rameters of a biophysical profi le and are detected with nonstress testing. Decreased or absent fetal movements may indicate central nervous system dysfunction or prematurity. Lack of fetal movement or decreased fetal movement is not associated with contraction stress testing. CN: Reduction of risk potential; CL: Analzye

58. While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, "I think my water just broke." Which of the following should the nurse do fi rst? ■ 1. Turn the client to the right side. ■ 2. Assess the color, amount, and odor of the fl uid. ■ 3. Assess the fetal heart rate pattern. ■ 4. Check the client's cervical dilation.

58. 3. After spontaneous rupture of the amni- otic fl uid, the gushing fl uid may carry the umbili- cal cord out of the birth canal. Sudden decelera- tion of the fetal heart rate commonly signifi es cord compression and/or prolapse of the cord, which would require immediate delivery. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the client to the right side is not a priority action. However, changing the client's position would be appropriate if variable decelerations are present. The nurse should assess the color, amount, and odor of the fl uid, but this can be done once the fetal heart rate is assessed and no problems are detected. Cervi- cal dilation should be checked but only after the fetal heart rate pattern is assessed. CN: Reduction of risk potential; CL: Synthesize

58. Which diagnostic test would be the most important to have for a primigravid client in the second trimester of her pregnancy? ■ 1. Culdocentesis to detect abnormalities. ■ 2. Chorionic villus sampling. ■ 3. Ultrasound testing. ■ 4. α-fetoprotein (AFP) testing.

58. 4. AFP testing is usually performed between the 15th and 18th weeks of gestation. Abnormally high levels found in maternal serum may be indica- tive of neural tube defects such as anencephaly and spina bifi da. Low levels may indicate trisomy 21 (Down syndrome). Culdocentesis is used to confi rm a tubal pregnancy. Chorionic villus sampling is done as early as 10 weeks' gestation to detect anomalies. Ultrasound testing may be done in the fi rst trimester to determine fetal viability and in the third trimester to determine pelvic adequacy and fetal or placental position. CN: Reduction of risk potential; CL: Apply

58. A diabetic postpartum client plans to breast- feed. The nurse determines that the client's under- standing of breast-feeding instructions is suffi cient when she states: ■ 1. "Insulin will be transferred to the baby through breast milk." ■ 2. "Breast-feeding is not recommended for dia- betic mothers." ■ 3. "Breast milk from diabetic mothers contains few antibodies." ■ 4. "Breast-feeding will assist in lowering mater- nal blood glucose."

58. 4. Breast-feeding consumes maternal calories and requires energy which increases the maternal basal metabolic rate and assists in lowering the mater- nal blood glucose level. Insulin is not transferred to the infant through breast milk. Breast-feeding is recommended for diabetic mothers because it does lower blood glucose levels. The number of antibodies in breast milk is not altered by maternal diabetes. CN: Physiological adaptation; CL: Evaluate

59. When performing Leopold's maneuvers, which of the following would the nurse ask the cli- ent to do to ensure optimal comfort and accuracy? ■ 1. Breathe deeply for 1 minute. ■ 2. Empty her bladder. ■ 3. Drink a full glass of water. ■ 4. Lie on her left side.

59. 2. Leopold's maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold's maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly. CN: Health promotion and maintenance; CL: Apply

59. Which of the following statements about a fetal biophysical profi le would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? ■ 1. It determines fetal lung maturity. ■ 2. It is noninvasive using real-time ultrasound. ■ 3. It will correlate with the newborn's Apgar score. ■ 4. It requires the client to have an empty bladder.

59. 2. The fetal biophysical profi le, a noninva- sive test using real-time ultrasound, assesses fi ve parameters: fetal heart rate reactivity, fetal breath- ing movements, gross fetal body movements, fetal tone, and amniotic fl uid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin- sphingomyelin ratio is used to determine fetal lung maturity. Although the fetal biophysical profi le is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound requires the mother to have a full bladder. CN: Pharmacological and parenteral therapies; CL: Apply

59. The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply. ■ 1. Assisting her to the bathroom. ■ 2. Applying an external fetal monitor to obtain fetal heart rate. ■ 3. Assessing her stage of labor. ■ 4. Asking if she had back labor pains like this with any of her other deliveries. ■ 5. Allowing her support person to take her to the bathroom to maintain privacy. ■ 6. Checking the degree of fetal descent.

59. 3, 6. The pressure from the fetus descending into the birth canal can cause the client to feel she needs to move her bowels and could be near deliv- ery. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in a delivery in the bathroom. Applying a fetal monitor may reassure the nurse that the fetus is doing well; however, it does not help to determine if the fetus is ready for delivery, which is the higher priority in this situation. Regardless of the client's prior experience with back labor pain, the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the feeling of pressure with a bowel movement. CN: Safety and infection control; CL: Synthesize

59. While caring for a neonate delivered at 32 weeks' gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist? ■ 1. The presence of 1 mL of gastric residual before a gavage feeding. ■ 2. Jaundice appearing on the face and chest. ■ 3. An increase in bowel peristalsis. ■ 4. Abdominal distention.

59. 4. Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, posi- tive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not signifi cant. Jaundice of the face and chest is associated with the neonate's immature liver func- tion and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis. CN: Physiological adaptation; CL: Analyze

59. A primiparous client who delivered a viable neonate 48 hours ago experienced a third-degree laceration. In preparation for discharge, the nurse instructs the client, who is breast-feeding her neonate, about perineal care. Which of the following client statements indicates the need for further instructions? ■ 1. "I can take acetaminophen every 3 to 4 hours or ibuprofen every 6 to 8 hours for the discomfort." ■ 2. "Warm sitz baths three or four times a day for 20 minutes can offer relief." ■ 3. "I should try to prevent constipation by drinking plenty of fl uids." ■ 4. "I can take an aspirin with codeine every 4 hours for the discomfort."

59. 4. Postpartum clients who are breast-feeding need to be cautioned about taking various medica- tions, many of which can be passed to the infant via breast milk. Aspirin and codeine products should be avoided because the drug can increase bleeding or cause sleepiness in the infant. Medi- cations such as ibuprofen or acetaminophen can be used to help to relieve the discomfort without causing any apparent harm to the neonate. Warm sitz baths three to four times a day for 20 minutes can be helpful in relieving the client's discomfort. Application of moist heat is soothing and increases perineal circulation. Increased fl uid (and fi ber) intake promotes bowel elimination, thus prevent- ing constipation, which can increase the client's discomfort. CN: Health promotion and maintenance; CL: Evaluate

6. After conducting a class for female adoles- cents about human reproduction, which of the fol- lowing statements indicates that the school nurse's teaching has been effective? ■ 1. "Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in preg- nancy." ■ 2. "I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle." ■ 3. "Sperm from a healthy male usually remain viable in the female reproductive tract for 96 hours." ■ 4. "After an ovum is fertilized by a sperm, the ovum then contains 21 pairs of chromosomes."

6. 1. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexu- ally active. Many people believe that the time in- terval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmit- ted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the woman is most likely to conceive. Using a 28-day cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibil- ity that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes. After fertilization, the conceptus contains 46 chromo- somes unless there is a chromosomal abnormality. CN: Health promotion and maintenance; CL: Evaluate

6. A septic preterm neonate's I.V. was removed due to infi ltration. While restarting the I.V., the nurse should carefully assess the neonate for: ■ 1. Fever. ■ 2. Hyperkalemia. ■ 3. Hypoglycemia. ■ 4. Tachycardia.

6. 3. Neonates that are septic use glucose at an increased rate. During the time the I.V. is not infus- ing, the neonate is using the limited glucose stores available to a preterm neonate and may deplete them. Hypoglycemia is too little glucose in the blood; without the constant infusion of I.V. glucose, hypoglycemia will result. Fevers and hyperkalemia are not related to glucose levels. Tachycardia is the result of untreated hypoglycemia. CN: Reduction of risk potential; CL: Analyze

6. A client is in the fourth stage of labor. Which set of assessments is the highest priority at this time? ■ 1. Assessment of the ability to push with con- tractions, hydration, and emotional stability. ■ 2. Assessment of maternal vital signs, fetal heart tones, and the contraction pattern. ■ 3. Assessment of maternal vital signs, the fun- dus, the bladder, and lochia. ■ 4. Assessment of maternal emotional status, infant bonding, and feeding preferences.

6. 3. Stage four is the fi rst 2 to 4 hours postpar- tum. At this time, the nurse should frequently assess maternal vital signs, the fundus, bladder status, and lochia. The vital signs indicate the ability of the client to transition from pregnancy to postpartum and the physical status of the mother. The mater- nal fundus should remain fi rm, midline, and at the umbilicus or lower. A bladder that is distended may displace the normally fi rm uterus and cause hemorrhage. The lochia is assessed for color, odor, and amount postpartum. Assessment of the mother's ability to push, hydration, emotional stability, con- traction patterns, and fetal heart tones is important in stages one and two. Maternal vital signs will be assessed during all stages of labor. Maternal emo- tional status and infant bonding and feeding prefer- ences are lower priorities than the physical well- being of the mother. CN: Reduction of risk potential; CL: Analyze

6. While caring for a moderately obese primi- gravid client in active labor at term, the nurse should monitor the client for signs of which of the following? ■ 1. Hypotonic refl exes. ■ 2. Increased uterine resting tone. ■ 3. Soft tissue dystocia. ■ 4. Increased fear and anxiety.

6. 3. The obese pregnant client is more suscep- tible to soft tissue dystocia, which can impede the progress of labor. Symptoms of soft tissue dystocia would include an arrest of labor, prolonged labor, or an arrest of descent of the fetus. Hypotonic refl exes are associated with magnesium sulfate therapy, and increased uterine resting tone is associated with hypertonic labor patterns in early labor, not with obesity and pregnancy. Increased fear and anxiety are also not associated with obesity. However, they may be associated with a primigravid client who does not know what to expect during labor. CN: Reduction of risk potential; CL: Analyze

6. A primigravid client's baseline blood pres- sure at her initial visit at 12 weeks' gestation was 110/70 mm Hg. During an assessment at 38 weeks' gestation, which of the following data would indi- cate mild preeclampsia? ■ 1. Blood pressure of 160/110 mm Hg on two separate occasions. ■ 2. Proteinuria, more than 5 g in 24 hours. ■ 3. Serum creatinine concentration of 1.4 mL/dL. ■ 4. Weight gain of 2 lb in the last week.

6. 4. A weight gain of 2 lb (0.9 kg) in the last week during the third trimester and mild peripheral edema are associated with mild preeclampsia. With severe preeclampsia, peripheral edema is extensive. Blood pressure readings of 160 mm Hg systolic and 100 mm Hg diastolic on two separate occasions and oliguria (urine output less than 400 mL in 24 hours) are signs of severe preeclampsia. Proteinuria, 3+ to 4+ or more than 5 g in a 24-hour sample, also indi- cates severe preeclampsia. Normal serum creatinine levels range from 0.5 to 1.1 mL/dL. A serum creati- nine concentration of 1.4 mL/dL is greatly elevated, indicating severe preeclampsia. CN: Physiological adaptation; CL: Analysis

60. During the home visit, a breast-feeding client asks the nurse what contraception method she and her husband should use until she has her 6-week postpartal examination. Which of the following would be most appropriate for the nurse to suggest? ■ 1. Condom with spermicide. ■ 2. Oral contraceptives. ■ 3. Rhythm method. ■ 4. Abstinence.

60. 1. If not contraindicated for moral, cultural, or religious reasons, a condom with spermicide is commonly recommended for contraception after delivery until the client's 6-week postpartal exami- nation. This method has no effect on the neonate who is breast-feeding. Oral contraceptives contain- ing estrogen are not advised for women who are breast-feeding because the hormones decrease the production of breast milk. Women who are not breast-feeding may use oral contraceptive agents. The rhythm method is not effective because the client is unlikely to be able to determine when ovulation has occurred until her menstrual cycle returns. Although breast-feeding is not considered an effective form of contraception, breast-feeding usually delays the return of both ovulation and menstruation. The length of the delay varies with the duration of lactation and the frequency of breast-feeding. While abstinence is one form of birth control and safe while breast-feeding, it may not be acceptable to this couple who is asking about a method that will allow them to resume sexual relations. CN: Health promotion and maintenance; CL: Synthesize

60. Which of the following statements by the mother of a neonate diagnosed with bronchopulmo- nary dysplasia (BPD) indicates effective teaching? ■ 1. "BPD is an acute disease that can be treated with antibiotics." ■ 2. "My baby may require permanent assisted ventilation." ■ 3. "Bronchodilators can cure my baby's condi- tion." ■ 4. "My baby may have seizures later on in life because of this condition."

60. 2. BPD is a chronic illness that may require prolonged hospitalization and permanent assisted ventilation. The disease typically occurs in compromised very-low-birth-weight neonates who require oxygen therapy and assisted ventilation for treat- ment of respiratory distress syndrome. The cause is multifactorial, and the disease has four stages. The neonate's activities may be limited by the disease. Antibiotics may be ordered, and bronchodilators may be used, but these medications will not cure the chronic disease state. Seizure activity is associated with periventricular-intraventricular hemorrhage, not BPD. CN: Physiological adaptation; CL: Evaluate

60. A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs dur- ing the fi rst trimester? ■ 1. They will increase. ■ 2. They will decrease. ■ 3. They will remain constant. ■ 4. They will be unpredictable.

60. 2. During the fi rst trimester, it is not unusual for insulin needs to decrease, commonly as a result of nausea and vomiting. Progressive insulin resis- tance is characteristic of pregnancy, particularly in the second half of pregnancy. It is not unusual for insulin needs to increase by as much as four times the nonpregnant dose after about the 24th week of gestation. This resistance is caused by the produc- tion of human placental lactogen, also called human chorionic somatotropin, by the placenta and by other hormones, such as estrogen and progesterone, which are insulin antagonists. CN: Pharmacological and parenteral therapies; CL: Apply

60. A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anes- thesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following? ■ 1. "The medication will be administered while I am in a side-lying position." ■ 2. "The anesthetic may cause a severe headache which is treatable." ■ 3. "My blood pressure may increase if I lie down too soon after the injection." ■ 4. "I can expect immediate anesthesia that can be reversed very easily."

60. 2. Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fl uid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a fl at position, or using a blood patch that can clot and seal off any further leakage of fl uid. Spinal anesthesia is administered with the client in a sitting position. Another adverse effect of spinal anesthesia is hypotension caused by vasodila- tion. General anesthesia provides immediate anes- thesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anes- thesia can be discontinued quickly when the anes- thesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off. CN: Pharmacological and parenteral therapies; CL: Evaluate

61. The nurse is assessing fetal position for a 32-year-old client in her eighth month of pregnancy. As shown below, the fetal position can be described as which of the following? pic ■ 1. Left occipital transverse. ■ 2. Left occipital anterior. ■ 3. Right occipital transverse. ■ 4. Right occipital anterior.

61. 1. In left occipital transverse lie, the occiput faces the woman's left hip. In left occipital anterior lie, the occiput faces the left anterior segment of the woman's pelvis. In right occipital transverse lie, the occiput faces the woman's right hip. In right occipi- tal anterior lie, the occiput faces the right anterior segment of the woman's pelvis. CN: Physiological adaptation; CL: Apply

61. When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension? ■ 1. Ephedrine sulfate. ■ 2. Epinephrine (Adrenalin Chloride). ■ 3. Methylergonovine (Methergine). ■ 4. Atropine sulfate.

61. 1. The drug of choice when hypotension occurs as a result of epidural anesthesia is ephed- rine sulfate because it provides a quick reversal of the vasodilator effects of the anesthesia. Epineph- rine is typically used to treat anaphylactic shock. Methylergonovine is a vasoconstrictor that is used for severe postpartum hemorrhage. Atropine sulfate is used to dry the oral and respiratory secretions and may be used during operative procedures. CN: Pharmacological and parenteral therapies; CL: Apply

61. The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year his- tory of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching? ■ 1. Candida albicans infection. ■ 2. Twin-to-twin transfer. ■ 3. Polyhydramnios. ■ 4. Preeclampsia.

61. 2. Clients who are pregnant and have diabe- tes are not at greater risk for multifetal pregnancy and subsequent twin-to-twin transfer unless they have undergone fertility treatments. The pregnant diabetic client is at higher risk for complications such as infection, polyhydramnios, ketoacidosis, and preeclampsia, compared with the pregnant non- diabetic client. CN: Reduction of risk potential; CL: Evaluate

61. A primiparous client who is beginning to breast-feed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with: ■ 1. More fat than breast milk. ■ 2. Vitamin K, which the neonate lacks. ■ 3. Delayed meconium passage. ■ 4. Passive immunity from maternal antibodies.

61. 4. Colostrum is a thin, watery, yellow fl uid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies (e.g., immuno- globulin A). It is important for the neonate to receive colostrum for passive immunity. Colostrum is lower in fat and lactose than mature breast milk. Colos- trum does not contain vitamin K. The neonate will produce vitamin K once a feeding pattern is estab- lished. Colostrum may speed, rather than delay, the passage of meconium. CN: Health promotion and maintenance; CL: Apply

61. A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respira- tions, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following? ■ 1. Placement of the neonate on a ventilator. ■ 2. Administration of bronchodilators through the nares. ■ 3. Suctioning of the neonate's nares with wall suction. ■ 4. Insertion of a chest tube into the neonate.

61. 4. The client data supports the diagnosis of pneumothorax which would be confi rmed with a chest X-Ray. Pneumothorax is an accumulation of air in the thoracic cavity between the parietal and vis- ceral pleurae and requires immediate removal of the accumulated air. Resolution is initiated with inser- tion of a chest tube connected to continuous negative pressure. The neonate does not need to be placed on a ventilator unless there is evidence of severe respi- ratory distress. The goal of treatment is to re-infl ate the collapsed lung. Administering bronchodilators through the nares or suctioning the neonates' nares would do nothing to aid in lung re-infl ation. CN: Physiological adaptation; CL: Synthesize

62. Which of the following statements by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?" ■ 1. "This usually disappears after delivery." ■ 2. "It is a sign of skin melanoma." ■ 3. "The discoloration is due to dilated capillaries." ■ 4. "It will fade if you use a prescribed cream."

62. 1. Discoloration on the face that commonly appears during pregnancy, called chloasma (mask of pregnancy), usually fades postpartum and is of no clinical signifi cance. The client who is bothered by her appearance may be able to decrease its promi- nence with ordinary makeup. Chloasma is not a sign of skin melanoma. It is not caused by dilated capillaries. Rather, it results from increased secre- tion of melanocyte-stimulating hormones caused by estrogen and progesterone secretion. No treatment is necessary for this condition. CN: Health promotion and maintenance; CL: Apply

62. When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, which of the following would the nurse expect to include as a desired target range for blood glucose levels? ■ 1. 40 to 60 mg/dL between 2:00 and 4:00 p.m. ■ 2. 60 to 100 mg/dL before meals and bedtime snacks. ■ 3. 110 to 140 mg/dL before meals and bedtime snacks. ■ 4. 140 to 160 mg/dL 1 hour after meals.

62. 2. The goal is to maintain blood plasma glucose levels at 60 to 100 mg/dL before meals and bedtime snacks. A range of 40 to 60 mg/dL indicates hypoglycemia. A range of 110 to 140 mg/dL suggests hyperglycemia. A range of 140 to 160 mg/dL 1 hour after meals suggests hyperglycemia. The target range 1 hour after meals is 100 to 120 mg/dL. CN: Pharmacological and parenteral therapies; CL: Synthesize

62. The physician determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean delivery with general anes- thesia. Before the cesarean delivery, the anesthesiol- ogist orders cimetidine (Tagamet) 300 mg PO. After administering the drug, the nurse should assess the client for reduction in which of the following? ■ 1. Incidence of bronchospasm. ■ 2. Oral and respiratory secretions. ■ 3. Acid level of the stomach contents. ■ 4. Incidence of postoperative gastric ulcer.

62. 3. Cimetidine (Tagamet) is ordered by some anesthesiologists who will be giving a general anesthetic to reduce the level of acid in the stom- ach contents, altering the pH to reduce the risk of complications should aspiration of vomitus occur. Aspiration of vomitus is the fi fth most common cause of maternal mortality. Most anesthesiologists insert an endotracheal tube to reduce the incidence of aspiration. Isoproterenol (Isuprel) is used to decrease the incidence of bronchospasm. Atropine sulfate is administered to dry oral and nasal secre- tions. Although cimetidine is useful for gastric ulcer therapy, gastric ulcers are not a common effect asso- ciated with operative deliveries. CN: Pharmacological and parenteral therapies; CL: Evaluate

62. Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding? ■ 1. Breast milk quality and richness are decreased. ■ 2. The mother's motivation to breast-feed is diminished. ■ 3. Medications may be excreted in breast milk to the nursing neonate. ■ 4. Medications interfere with the mother's let- down refl ex.

62. 3. Various medications can be excreted in the breast milk and affect the nursing neonate. The client should avoid all nonprescribed medications (such as acetaminophen) unless approved by the physician. Medications typically do not affect the quality of the mother's breast milk. Medications usu- ally do not interfere with or diminish the mother's motivation to breast-feed, nor do they interfere with the mother's let-down refl ex. CN: Health promotion and maintenance; CL: Apply

63. A newborn weighing 61⁄2 lb is to be given naloxone hydrochloride (Narcan) due to respira- tory depression as a result of a narcotic given to the mother shortly before delivery. The drug is to be given 0.01 mg/kg into the umbilical vein. The vial is marked 0.4 mg/mL. How many milligrams would the newborn receive? Round to two decimals. ________________________ mg.

63. 0.03 mg 61⁄2 lb ÷ 2.2 = 2.95 kg 2.95 kg × 0.01 mg = 0.029 mg, rounded to 0.03 mg CN: Pharmacological and parenteral therapies; CL: Apply

63. The nurse prepares a client for lumbar epi- dural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions? ■ 1. Lithotomy. ■ 2. Side-lying. ■ 3. Knee-to-chest. ■ 4. Prone.

63. 2. Lumbar epidural anesthesia is usually administered with the client in a sitting or a left side-lying position with shoulders parallel and legs slightly fl exed. These positions expose the vertebrae to the anesthesiologist. Paracervical and local anes- thetics are usually administered with the client in the lithotomy position. The knee-to-chest and prone positions are not used for anesthesia administration. CN: Pharmacological and parenteral therapies; CL: Apply

63. When teaching a primigravid client with diabetes about common causes of hyperglycemia during pregnancy, which of the following would the nurse include? ■ 1. Fetal macrosomia. ■ 2. Obesity before conception. ■ 3. Maternal infection. ■ 4. Pregnancy-induced hypertension.

63. 3. Maternal infection is the most common cause of maternal hyperglycemia and can lead to ketoacidosis, coma, and death. The client should notify the physician immediately if she experiences symptoms of an infection. Fetal macrosomia, obesity before conception, and pregnancy-induced hyper- tension are not associated with maternal hypergly- cemia during pregnancy. CN: Physiological adaptation; CL: Create

63. A breast-feeding primiparous client with a midline episiotomy is prescribed ibuprofen 200 mg orally. The nurse instructs the client to take the medication: ■ 1. Before going to bed. ■ 2. Midway between feedings. ■ 3. Immediately after a feeding. ■ 4. When providing supplemental formula.

63. 3. Taking ibuprofen 200 mg orally immedi- ately after breast-feeding helps minimize the neo- nate's exposure to the drug because drugs are most highly concentrated in the body soon after they are taken. Most mothers breast-feed on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decreased by the next breast-feeding ses- sion. Taking the medication before going to bed is inappropriate because, although the mother may go to bed at a certain time, the neonate may wish to breast-feed soon after the mother goes to bed. If the mother takes the medication midway between feedings, then its peak action may occur midway between feedings. Breast milk is suffi cient for the neonate's nutritional needs. Most breast-feeding mothers should not be encouraged to provide supplemental feedings to the infant because this may result in nipple confusion. CN: Pharmacological and parenteral therapies; CL: Apply

63. A 36-year-old primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. The nurse should assess the client's fundal height to: ■ 1. Determine the level of uterine activity. ■ 2. Identify the need for increased weight gain. ■ 3. Assess the location of the placenta. ■ 4. Estimate the fetal gestational age.

63. 4. Assessment of fundal height is a gross estimate of gestational age. By 20 weeks' gestation, the height of the fundus should be at the level of the umbilicus, after which it should increase 1 cm for each week of gestation until approximately 36 weeks' gestation. Fundal height that is signifi - cantly different from that implied by the estimated gestational age warrants further evaluation (e.g., ultrasound examination), because it possibly indi- cates multiple pregnancy or fetal growth retardation. Fundal height estimation will not determine uterine activity or a need for increased weight gain. Ultra- sound examination, not fundal height estimation, will locate the placenta. CN: Health promotion and maintenance; CL: Apply

64. After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia, the nurse determines that the client understands the instruction when she says that hyperglycemia may be manifested by which of the following? ■ 1. Dehydration. ■ 2. Pallor. ■ 3. Sweating. ■ 4. Nervousness.

64. 1. Dehydration, polyuria, fatigue, fl ushed hot skin, dry mouth, and drowsiness are manifesta- tions of hyperglycemia. Hyperglycemia is a medical emergency and requires immediate action to prevent maternal and fetal mortality. Pallor, sweating, and nervousness are early signs of hypoglycemia, not hyperglycemia. CN: Reduction of risk potential; CL: Evaluate

64. The nurse is assessing the perineal changes of a multigravid client in the second stage of labor. The illustration below represents which of the fol- lowing perineal changes? pic ■ 1. Anterior-posterior slit. ■ 2. Oval opening. ■ 3. Circular shape. ■ 4. Crowning.

64. 2. Anterior-posterior slit occurs as the perineum fl attens and is followed by an oval open- ing. As labor progresses, the perineum takes on a circular shape. Crowning occurs when the fetal head is visible. CN: Physiological adaptation; CL: Apply

64. After the nurse reviews the physician's explanation of amniocentesis with a multigravid cli- ent, which of the following indicates that the client understands a serious risk of the procedure.? ■ 1. Premature rupture of the membranes. ■ 2. Possible premature labor. ■ 3. Fetal limb malformations. ■ 4. Fetal organ malformations.

64. 2. One of the primary risks of amniocentesis is stimulation of the uterus and subsequent preterm labor. Other risks include hemorrhage from penetra- tion of the placenta, infection of the amniotic fl uid, and puncture of the fetus. There is little risk for rup- ture of the membranes, fetal limb malformations, or fetal organ malformations, if a practitioner skilled in using ultrasound performs the procedure. Fetal limb malformations have been associated with percutane- ous umbilical blood sampling. CN: Reduction of risk potential; CL: Evaluate

95. A primiparous client who underwent a cesar- ean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the fol- lowing time frames after delivery? ■ 1. 8 hours. ■ 2. 24 hours. ■ 3. 72 hours. ■ 4. 96 hours.

95. 3. For maximum effectiveness, RhoGAM should be administered within 72 hours postpar- tum. Most Rh-negative clients also receive RhoGAM during the prenatal period at 28 weeks' gestation and then again after delivery. The drug is given to Rh-negative mothers who have a negative Coombs test and deliver Rh-positive neonates. If there is doubt about the fetus's blood type after preg- nancy is terminated, the mother should receive the medication. CN: Pharmacological and parenteral therapies; CL: Apply

64. Which of the following would the nurse include in the teaching plan for a primiparous client about the frequency of breast-feeding the neonate during the fi rst few days? ■ 1. Feeding the neonate whenever he or she cries. ■ 2. Restricting feedings to 1 to 2 minutes per side. ■ 3. Feeding the neonate for at least 10 minutes per side. ■ 4. Maintaining feeding for 20 to 30 minutes per side.

64. 3. During the fi rst few days postpartum, the mother should be encouraged to nurse frequently. Breast-feeding for at least 10 minutes per side is rec- ommended for the let-down refl ex to begin. Feeding the infant whenever the infant cries is not appropri- ate and can lead to maternal exhaustion. Feeding for 1 to 2 minutes per side is insuffi cient for the let- down refl ex. Also, this short period of time prevents the neonate from latching on and obtaining the needed nutrition. Initially, feeding for 10 minutes per side is suffi cient until the infant becomes more comfortable with breast-feeding. Then the mother can increase the breast-feeding time gradually to 20 to 30 minutes. CN: Health promotion and maintenance; CL: Apply

65. After suctioning to clear the airway of a term neonate who appears in good condition after spon- taneous vaginal delivery, which of the following would the nurse do next? ■ 1. Place the infant in a radiant warmer. ■ 2. Instill erythromycin in the eyes. ■ 3. Obtain the neonate's weight. ■ 4. Put identification bracelets on each wrist.

65. 1. A neonate in good condition needs to be kept warm. This reduces cold stress and potential respiratory problems. Cold stress causes the neonate to burn much-needed brown fat. The infant can be evaluated under a radiant warmer or wrapped in dry, warm blankets on the mother's abdomen. Instilling erythromycin ointment, weighing the neonate, and applying identifi cation bracelets can be done once the neonate has been placed under a radiant warmer and the temperature has stabilized. CN: Health promotion and maintenance; CL: Synthesize

65. At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following fi ndings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin. Which of these fi ndings warrants further assessment? ■ 1. Frequent hiccups. ■ 2. Loose, watery stool in diaper. ■ 3. Pink papular vesicles on the face. ■ 4. Dry, peeling skin.

65. 2. A loose, watery stool in the diaper is indic- ative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the neonate, compared with the adult. Frequent hiccups are considered normal in a neonate and do not warrant additional investigation. Pink papular vesicles (erythema toxicum) on the face are considered normal in a neonate and disap- pear without treatment. Dry, peeling skin is normal in a post-term neonate. CN: Health promotion and maintenance; CL: Analyze

65. A primigravid client at 28 weeks' gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hundred miles away. Which of the following recommenda- tions by the nurse would be best? ■ 1. "Try to avoid traveling anywhere in the car during your third trimester." ■ 2. "Limit the time you spend in the car to a maximum of 4 to 5 hours." ■ 3. "Taking the trip is okay if you stop every 1 to 2 hours and walk." ■ 4. "Avoid wearing your seat belt in the car to prevent injury to the fetus."

65. 3. The client traveling by automobile should be advised to take intermittent breaks of 10 to 15 minutes, including walking, every 1 to 2 hours to stimulate the circulation, which becomes sluggish during long periods of sitting. Automobile travel is not contraindicated during pregnancy unless the client develops complications. There is no set maximum number of hours allowed. The pregnant client should always wear a seat belt when traveling by automobile. The client should be aware of the nearest health care facility in the city to which she is traveling. CN: Reduction of risk potential; CL: Apply

65. A multiparous client, 28 hours after cesarean delivery, who is breast-feeding complains of severe cramps or afterpains. The nurse explains that these are caused by which of the following? ■ 1. Flatulence accumulation after a cesarean delivery. ■ 2. Healing of the abdominal incision after cesar- ean delivery. ■ 3. Adverse effects of the medications adminis- tered after delivery. ■ 4. Release of oxytocin during the breast-feeding session.

65. 4. Breast-feeding stimulates oxytocin secre- tion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains. Flatulence may occur after a cesarean delivery. However, the mother typically would complain of abdominal distention and a bloating feeling, not a "cramplike" feeling. Stretching of the tissues or healing may cause slight t enderness or itching, not cramping feelings of discomfort. Medications such as mild analgesics or stool softeners, commonly administered postpartum, typically do not cause cramping. CN: Health promotion and maintenance; CL: Apply

65. At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preec- lampsia is admitted for a cesarean delivery. The nurse explains to the client that delivery helps to prevent which of the following? ■ 1. Neonatal hyperbilirubinemia. ■ 2. Congenital anomalies. ■ 3. Perinatal asphyxia. ■ 4. Stillbirth.

65. 4. Stillbirths caused by placental insuffi - ciency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unan- ticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean delivery is necessary. Induction and cesarean delivery do not prevent neonatal hyper- bilirubinemia, congenital anomalies, or perinatal asphyxia. CN: Reduction of risk potential; CL: Apply

66. After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching? ■ 1. "I need to increase my intake of vitamin D." ■ 2. "I should drink at least fi ve glasses of fl uid daily." ■ 3. "I need to get an extra 500 calories per day." ■ 4. "I need to make sure I have enough calcium in my diet."

66. 2. For the breast-feeding client, drinking at least 8 to 10 glasses of fl uid a day is recommended. Breast-feeding women need an increased intake of vitamin D for calcium absorption. A breast-feeding woman requires an extra 500 calories per day above the recommended nonpregnancy intake to produce quality breast milk. Breast-feeding women need adequate calcium for blood clotting and strong bones and teeth. CN: Basic care and comfort; CL: Evaluate

66. When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next? ■ 1. Determine the length of the mother's labor. ■ 2. Notify the pediatrician immediately. ■ 3. Keep the neonate under the radiant warmer for 2 hours. ■ 4. Obtain a blood sample to check for hypoglycemia.

66. 2. Ortolani's maneuver involves fl exing the neonate's knees and hips at right angles and bring- ing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani's sign, suggesting a possible hip dislocation. The nurse should notify the physician promptly because treat- ment is needed, while maintaining the dislocated hip in a position of fl exion and abduction. Deter- mining the length of the mother's labor provides no useful information related to the nurse's fi nding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indi- cated at this time, unless the neonate is exhibiting jitteriness. CN: Reduction of risk potential; CL: Synthesize

66. A primigravid client with diabetes at 39 weeks' gestation is seen in the high-risk clinic. The physician estimates that the fetus weighs at least 4,500 g (10 lb). The client asks, "What causes the baby to be so large?" The nurse's response is based on the understanding that fetal macrosomia is usually related to which of the following? ■ 1. Family history of large infants. ■ 2. Fetal anomalies. ■ 3. Maternal hyperglycemia. ■ 4. Maternal hypertension.

66. 3. Maternal hyperglycemia and poor con- trol of the mother's diabetes mellitus have been implicated in fetal macrosomia. When the mother is hyperglycemic, large amounts of amino acids, free fatty acids, and glucose are transferred to the fetus. Although maternal insulin does not cross the placenta, the fetal pancreas responds by hypertrophy of the islet cells of the pancreas. The islet cells produce large amounts of insulin, which acts as a growth hormone. A family history of large infants usually is not the reason for large- for-gestational-age fetuses in diabetic mothers. Maternal hypertension is associated with small- for-gestational-age fetuses because of vasocon- striction of the maternal and placental blood vessels. CN: Physiological adaptation; CL: Apply

The Labor Experience 66. A client is admitted at 30 weeks' gestation with contractions every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, I.V. magnesium sulfate is infusing at 2 g/hour. How will the nurse know the medication is having the intended effect? ■ 1. Contractions will increase in frequency, lead- ing to delivery. ■ 2. The client will maintain a respiratory rate greater than 12 breaths per minute. ■ 3. Contractions will decrease in frequency, intensity, and duration. ■ 4. The client will maintain blood pressure read- ings of 120/80 mm Hg.

66. 3. The expected outcome of magnesium sulfate administration is suppression of the contractions because the client is in preterm labor. Mag- nesium sulfate is a smooth muscle relaxant used to slow and stop contractions. Having contractions that lead to delivery is not the intended effect of this drug when used for preterm labor. Respirations lower than 12 breaths/minute may indicate magne- sium sulfate toxicity. Another use of magnesium sul- fate is to treat preeclampsia by preventing seizures and, secondarily, lowering maternal blood pres- sure. However, in this scenario, preterm labor—not preeclampsia—is being treated. CN: Pharmacological and parenteral therapies; CL: Evaluate

67. With plans to breast-feed her neonate, a pregnant client with insulin-dependent diabetes asks the nurse about insulin needs during the post- partum period. Which of the following statements about postpartal insulin requirements for breast- feeding mothers should the nurse include in the explanation? ■ 1. They fall signifi cantly in the immediate post- partum period. ■ 2. They remain the same as during the labor process. ■ 3. They usually increase in the immediate post- partum period. ■ 4. They need constant adjustment during the fi rst 24 hours.

67. 1. Insulin needs fall signifi cantly for the fi rst 24 hours postpartum because the client has usu- ally been on nothing-by-mouth status for a period of time during labor and the labor process has used maternal glycogen stores. If the client breast-feeds, lower blood glucose levels decrease the insulin re- quirements. With insulin resistance gone, the client commonly needs little or no insulin during the im- mediate postpartum period. Although the need for insulin decreases during the intrapartum period, the insulin requirements fall further during the fi rst 24 hours postpartum. After the fi rst 24 hours postpartum, insulin requirements may fl uctuate markedly, needing adjustment during the next few days as the mother's body returns to a nonpregnant state. CN: Pharmacological and parenteral therapies; CL: Create

67. The client is breast-feeding and asks the nurse about nutrition and diet. Which of the follow- ing statements by the client indicate understanding of dietary needs to promote successful breast- feeding? Select all that apply. ■ 1. "I need to increase the number of meals I eat from three to fi ve each day." ■ 2. "I have to add about 500 more calories to my diet while I breast-feed." ■ 3. "I need at least two servings of protein, like meat or eggs, with each meal." ■ 4. "I need to double my fl uids from my normal three to six glasses each day." ■ 5. "I can include fats in my diet now." ■ 6. "I can eat more cheese and drink orange juice with calcium to increase my calcium intake."

67. 2, 3, 4, 5, 6. To maintain adequate milk supply, lactating women need to increase their calories by 500. They also need to increase protein (to 7 serv- ings daily), fl uid (4 to 5 glasses of milk plus 2 addi- tional glasses), fat (from sparing use prepregnancy to 5 daily servings), and calcium intake (1,000 to 1,200 mg daily). CN: Health promotion and maintenance; CL: Evaluate

67. Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks' gestation who is complaining of leg cramps? ■ 1. Change positions frequently throughout the day. ■ 2. Alternately fl ex and extend the legs. ■ 3. Straighten the knee and fl ex the toes toward the chin. ■ 4. Lie prone in bed with the legs elevated.

67. 3. Leg cramps are thought to result from excessive amounts of phosphorus absorbed from milk products. Straightening the knee and fl exing the toes toward the chin is an effective measure to relieve leg cramps. Also, decreasing milk intake and supplementing with calcium lactate may help to reduce the cramping. Keeping the legs warm and elevating them are good preventive measures. Changing positions frequently aids venous return but is not helpful in relieving leg cramps. Alter- nately fl exing and extending the legs will not help to relieve the leg cramp. Lying prone in the bed is a diffi cult position for a client at 37 weeks' gestation to achieve and maintain because of the increase in abdominal size and therefore is not considered helpful. CN: Basic care and comfort; CL: Synthesize

67. A client at 33 weeks' gestation is admit- ted in preterm labor. She is given betamethasone (Celestone) 12 mg I.M. q 24 hours × 2. What is the expected outcome of this drug therapy? ■ 1. The contractions will end within 24 hours. ■ 2. The client will deliver a neonate without respiratory distress. ■ 3. The client will deliver a full-term neonate. ■ 4. The neonate will be delivered with mature lungs.

67. 4. Betamethasone is a corticosteroid that induces the production of surfactant. The pulmo- nary maturation that results causes the fetal lungs to mature more rapidly than normal. Because the lungs are mature, the risk of respiratory distress in the neonate is lowered but not eliminated. Betametha- sone also decreases the surface tension within the alveoli. Betamethasone has no infl uence on contrac- tions or carrying the fetus to full term. CN: Pharmacological and parenteral therapies; CL: Evaluate

67. A neonate is admitted to the neonatal inten- sive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. Which of the following nursing diagnoses would be the priority for this neonate? ■ 1. Impaired skin integrity related to post-term status. ■ 2. Imbalanced nutrition: More than body requirements related to large size. ■ 3. Risk for impaired parent-infant-child attach- ment related to transfer to the intensive care unit. ■ 4. Impaired gas exchange related to the effects of respiratory distress.

67. 4. The priority nursing diagnosis for the neo- nate with probable MAS is Impaired gas exchange related to the effects of respiratory distress. Obstruc- tion of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing adequate respirations is the primary goal. Impaired skin integrity related to post-term status is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Although nutrition may be altered, oxygen- ation takes priority over nutrition. If the parents do not express interest or concern for the neonate, then Risk for impaired parent-infant-child attachment may be appropriate once the airway is established. CN: Physiological adaptation; CL: Analyze

68. A full-term client is admitted for an induc- tion of labor. The health care provider has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? ■ 1. Oxytocin (Pitocin) 10 units in 500 mL D5 W. ■ 2. Prostaglandin gel (Prepidil) 0.5 mg. ■ 3. Misoprostol (Cytotec) 50 mcg P.O. ■ 4. Dinoprostone (Cervidil) 10 mg.

68. 1. A Bishop score evaluates cervical readi- ness for labor based on fi ve factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using Pitocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a -1 to 0 posi- tion. Prepidil, Cytotec, and Cervidil are all cervical ripening agents and the doses are accurate; however, cervical ripening has already taken place. CN: Pharmacological and parenteral therapies; CL: Synthesize

68. A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following? ■ 1. Fat. ■ 2. Iron. ■ 3. Sodium. ■ 4. Calcium.

68. 1. Breast milk has a higher fat content than cow's milk. Thirty percent to fi fty fi ve percent of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk. CN: Basic care and comfort; CL: Apply

68. When developing the initial plan of care for a neonate who was born at 41 weeks' gestation, was diagnosed with meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse include? ■ 1. Care of an umbilical arterial line. ■ 2. Frequent ultrasound scans. ■ 3. Orogastric feedings as soon as possible. ■ 4. Assessment for symptoms of hyperglycemia.

68. 1. Care of an umbilical arterial line would be included in the neonate's plan of care because an umbilical arterial line is commonly inserted to monitor arterial blood pressures, blood pH, blood gases, and infusion of intravenous fl uids, blood, or medications. Frequent ultrasound scans are not indicated at this time. However, chest radiographs may be used to detect lung densities, because pneumonia is a major complication of this disorder. Orogastric feeding may not be feasible while the health care team focuses on interventions to estab- lish adequate oxygenation. The neonate with MAS commonly experiences hypoglycemia, not hypergly- cemia. Hypoglycemia occurs because of depletion of glucose stores related to hypothermia. CN: Physiological adaptation; CL: Synthesize

68. Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gesta- tion who is experiencing occasional heartburn? ■ 1. Eat smaller and more frequent meals during the day. ■ 2. Take a pinch of baking soda with water before meals. ■ 3. Decrease fl uid intake to four glasses daily. ■ 4. Drink several cups of regular tea throughout the day.

68. 1. Eating smaller and more frequent meals may help prevent heartburn because acid produc- tion is decreased and stomach displacement is reduced. Heartburn can occur at any time during pregnancy. Contributing factors include stress, tension, worry, fatigue, caffeine, and smoking. Certain spicy foods (e.g., tacos) may trigger heart- burn in the pregnant client. The client should be advised to avoid sodium bicarbonate antacids (e.g., Alka- Seltzer), baking soda, Bicitra or sodium citrate, and fatty foods, which are high in sodium and can contribute to fl uid retention. Increasing, not decreasing, fl uid intake may help to relieve heartburn by diluting gastric juices. Caffeinated products such as coffee or tea can stimulate acid formation in the stomach, further contributing to heartburn. CN: Basic care and comfort; CL: Synthesize

68. After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart dis- ease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching? ■ 1. "I should avoid being near people who have a cold." ■ 2. "I may be given antibiotics during my pregnancy." ■ 3. "I should reduce my intake of protein in my diet." ■ 4. "I should limit my salt intake at meals."

68. 3. The client needs a diet that is adequate in protein and calories to prevent anemia, which can place additional strain on the cardiac system, fur- ther compromising the client's cardiac status. The client should avoid contact with people who have infections because of the increased risk for develop- ing endocarditis. The client may need antibiotics during the pregnancy to prevent endocarditis. Limit- ing sodium intake can help to prevent excessive expansion of blood volume and decrease cardiac workload. CN: Reduction of risk potential; CL: Evaluate

69. A full-term client is admitted for induction of labor. When admitted, her cervix is 25/0. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction? ■ 1. Nalbuphine (Nubain). ■ 2. Oxytocin (Pitocin). ■ 3. Dinoprostone (Cervidil). ■ 4. Betamethasone (Celestone).

69. 3. Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must occur before the cervix can efface and dilate with oxyto- cin (Pitocin). Drugs to accomplish this goal include dinoprostone (Cervidil), misoprostol (Cytotec), and prostaglandin E2 (PGE2). Nubain is a narcotic anal- gesic used in early labor and has no infl uence on the cervix. Betamethasone (Celestone) is a corticosteroid given to mature fetal lungs. CN: Pharmacological and parenteral therapies; CL: Apply

69. While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her physi- cian immediately if the client experiences which of the following? ■ 1. Mild ankle edema. ■ 2. Emotional stress on the job. ■ 3. Weight gain of 1 lb in 1 week. ■ 4. Increased dyspnea at rest.

69. 4. Increased dyspnea at rest must be reported immediately because it may be indicative of increas- ing congestive heart failure. Mild ankle edema in the third trimester is a common fi nding. However, generalized or pitting edema, suggesting increasing congestive heart failure, must be reported immedi- ately. Emotional stress on the job increases cardiac demand. However, it needs to be reported only if the client experiences symptoms, such as palpitations or irregular heart rate, indicating heart failure re- lated to the increased stress. Weight gain of 1 lb per week is a normal fi nding during the third trimester. CN: Reduction of risk potential; CL: Apply

69. While assisting a primiparous client with her fi rst breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple? ■ 1. Pull down gently on the neonate's chin and insert the nipple. ■ 2. Squeeze both of the neonate's cheeks simultaneously. ■ 3. Place the nipple into the neonate's mouth on top of the tongue. ■ 4. Brush the neonate's lips lightly with the nipple.

69. 4. Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking. The neonate should be taught to open the mouth and grasp the nipple on his or her own. The neonate should not be forced to nurse. CN: Health promotion and maintenance; CL: Apply

69. A post-term neonate diagnosed with persis- tent pulmonary hypertension is prescribed intrave- nous tolazoline (Priscoline). While administering this drug, the nurse should monitor the neonate for? ■ 1. Feeding behaviors. ■ 2. Temperature. ■ 3. Skin color. ■ 4. Blood pressure.

69. 4. Tolazoline (Priscoline) can cause profound hypotension. Therefore, the nurse should monitor the neonate's blood pressure when giving this drug. Adverse effects of the medication include petechiae, dark stools, bleeding, and diarrhea. Plasma expanders are commonly used with tolazoline to prevent dramatic changes in blood pressure. Feed- ing behaviors, temperature, and skin color are rou- tine assessments for all neonates, unrelated to the use of tolazoline. CN: Pharmacological and parenteral therapies; CL: Analyze

7. The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which of the following instructions should the nurse give to the mother? ■ 1. Continue feeding every 3 to 4 hours since the weight loss is normal. ■ 2. Contact the physician if the weight loss con- tinues over the next few days. ■ 3. Switch to a soy-based formula because the current one seems inadequate. ■ 4. Change to a higher-calorie formula to prevent further weight loss.

7. 1. This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the fi rst few days after birth, most likely because of minimal nutritional intake. With bottle-feeding, the neonate's intake varies from one feeding to another. Addition- ally, the neonate experiences a loss of extracellular fl uid. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the physician should be called. CN: Health promotion and maintenance; CL: Synthesize

7. A primigravid client delivered vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpar- tum goal would have the highest priority? ■ 1. By discharge, the family will bond with the neonate. ■ 2. The client will demonstrate self-care and infant care by the end of the shift. ■ 3. The client will state instructions for discharge during the fi rst postpartum day. ■ 4. By the end of the shift, the client will describe a safe home environment.

7. 2. Educating the client about caring for herself and her infant are the two highest priority goals. Following delivery, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specifi c needs of each client. Bonding is signifi cant, but is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety. CN: Management of care; CL: Create

7. The nurse is caring for a primigravid client in active labor at 42 weeks' gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by: ■ 1. Changing her pushing position every 15 minutes. ■ 2. Notifying the health care provider of her cur- rent status. ■ 3. Continuing with current pushing technique. ■ 4. Assessing the client's current pain and fetal status.

7. 2. The normal length of time for pushing is 2 hours. Anything over that time becomes an abnor- mal situation and the health care provider needs to be notified. Changing the client's position is an appropriate nursing action within the 2-hour time period based on client need and fetal descent. Con- tinuing current pushing supports techniques that have not been successful in delivering this client within the 2-hour time frame. Assessing client pain and fetal status are standards of care for laboring clients, but will not expedite the delivery of a client who has been pushing this long. CN: Safety and infection control; CL: Synthesize

7. A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which of the following would the nurse include in the teaching plan? ■ 1. This method has a 50% failure rate during the fi rst year of use. ■ 2. Couples must abstain from coitus for 5 days after the menses. ■ 3. Cervical mucus is carefully monitored for changes. ■ 4. The male partner uses condoms for signifi cant effectiveness.

7. 3. The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regu- lar menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close moni- toring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning. CN: Health promotion and maintenance; CL: Create

7. A 16-year-old client at 34 weeks' gestation, who is being monitored at home with home nurs- ing visits, is diagnosed with mild preeclampsia and has gained 2 lb in the past week. Her current blood pressure is 144/92 mm Hg. Which assessment fi nd- ing would require further action by the home health nurse? ■ 1. Occasional headache. ■ 2. Frequent voiding in large amounts. ■ 3. 1 + pedal edema. ■ 4. 3 + protein on urine dipstick.

7. 4. Protein on the urine dipstick with mild preeclampsia should not exceed 1 + and should be followed by a 24-hour urine collection. Oc- casional headache is normal but if these should increase in frequency and change in character, they would need to be further evaluated. Frequent voiding in large amounts is not related to preec- lampsia. 1+ pedal edema is a frequent occurrence in a pregnant client, especially during the later part of pregnancy. CN: Reduction of risk potential; CL: Analyze

70. A nurse is attempting to resuscitate a neo- nate. After following the Neonatal Resuscitation Program guidelines, 30 seconds of chest compres- sions have been completed. The neonate's heart rate remains less than 60 bpm. Epinephrine is given. What is the expected outcome for a neonate who has received epinephrine during resuscitation? ■ 1. Increased urine output. ■ 2. A normal heart rate. ■ 3. Pain relief. ■ 4. Sedation.

70. 2. Epinephrine is given for severe bradycar- dia and hypotension. An expected outcome would be an increased heart rate to a normal range. Epi- nephrine decreases renal blood fl ow, so a decrease in urine output would be expected. Epinephrine also stimulates alpha- and beta-adrenergic receptors, which do not offer pain relief or sedation. CN: Pharmacological and parenteral therapies; CL: Evaluate

70. When performing Leopold's maneuvers on a primigravid client at 22 weeks' gestation, the nurse per- forms the fi rst maneuver to do which of the following? ■ 1. Locate the fetal back and spine. ■ 2. Determine what is in the fundus. ■ 3. Determine whether the fetal head is at the pelvic inlet. ■ 4. Identify the degree of fetal descent and fl exion.

70. 2. In the fi rst maneuver, which is done with the nurse facing the client's head, both hands are used to palpate and determine which fetal body part (e.g., the head or buttocks) is in the fundus. This fi rst maneuver helps to determine the presenting part of the fetus. In the second maneuver, also done with the nurse facing the client's head, the palms of both hands are used to palpate the sides of the uterus and determine the location of the fetal back and spine. In the third maneuver, one hand gently grasps the lower portion of the abdomen just above the symphysis pubis to determine whether the fetal head is at the pelvic inlet. The fourth maneuver, done with the nurse facing the client's feet, deter- mines the degree of fetal descent and fl exion into the pelvis. CN: Health promotion and maintenance; CL: Apply

70. A 25-year-old primiparous client who deliv- ered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the high- est priority in the teaching plan about preventing nipple soreness? ■ 1. Keeping plastic liners in the brassiere to keep the nipple drier. ■ 2. Placing as much of the areola as possible into the baby's mouth. ■ 3. Smoothly pulling the nipple out of the mouth after 10 minutes. ■ 4. Removing any remaining milk left on the nipple with a soft washcloth.

70. 2. Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorge- ment, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple sore- ness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 min- utes may prevent the baby from getting the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off, because the milk has healing properties.

70. The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client states which of the following? ■ 1. "Nubain (nalbuphine) and Phenergan (promethazine) will give relief from pain and nausea during early labor." ■ 2. "I can have an epidural as soon as I start contracting." ■ 3. "If I have a cesarean, I can have an epidural." ■ 4. "If I have an emergency cesarean, I may be put to sleep for the delivery."

70. 2. Typically, a client will be able to have an epidural when she is 3 to 4 cm dilated or the active phase of labor has been established. Waiting until the cervix is dilated to this point ensures that the client is in labor and the epidural is less likely to halt labor contractions. Nubain and Phenergan are used to provide relief until the client is about 7 cm dilated. If given after this time, narcotics may cause neonatal respiratory depression in the neonate. The majority of clients have an epidural or spinal for a cesarean section. The only time general anesthesia is used is for an emergency cesarean section. CN: Pharmacological and parenteral therapies; CL: Evaluate

70. When developing the collaborative plan of care with the health care provider for a multigravid client at 10 weeks' gestation with a history of car- diac disease who was being treated with digitalis therapy before this pregnancy, the nurse should instruct the client about which of the following regarding the client's drug therapy regimen? ■ 1. Need for an increased dosage. ■ 2. Continuation of the same dosage. ■ 3. Switching to a different medication. ■ 4. Addition of a diuretic to the regimen.

70. 2. Unless the client has cardiac decompensa- tion during the pregnancy, she will most likely be able to continue taking the same dose of medication. The client may be prescribed prophylactic antibi- otics, particularly if she has had rheumatic fever. The medication would be switched only if digitalis toxicity occurs. A diuretic is added only if conges- tive heart failure is not controlled by sodium and activity restrictions. CN: Management of care; CL: Apply

71. The health care provider has performed an amniotomy on a laboring client. Which of the fol- lowing details must be included in the documenta- tion of this procedure? Select all that apply. ■ 1. Time of rupture. ■ 2. Color and clarity of fl uid. ■ 3. Fetal heart rate (FHR) and pattern before and after the procedure. ■ 4. Size of amnio-hook used during the proce- dure. ■ 5. Odor and amount of fl uid.

71. 1, 2, 3, 5. The time of rupture; color, odor, amount, and clarity of amniotic fl uid; and FHR and pattern before and after the procedure are all infor- mation that must be documented on the client's record. There is only one size for an amnio-hook. CN: Management of care; CL: Create

71. Which of the following client statements indicates effective teaching about burping a breast- fed neonate? ■ 1. "Breast-fed babies who are burped frequently will take more on each breast." ■ 2. "If I supplement the baby with formula, I will rarely have to burp him." ■ 3. "I'll breast-feed my baby every 3 hours so I won't have to burp him." ■ 4. "When I switch to the other breast, I'll burp the baby."

71. 4. Breast-fed neonates do not swallow as much air as bottle-fed neonates, but they still need to be burped. Good times to burp the neonate are when the mother switches from one breast to the other and at the end of the breast-feeding ses- sion. Neonates do not eat more if they are burped frequently. Breast-feeding mothers are advised not to supplement the feedings with formula because this may cause nipple confusion and decrease milk production. If supplements are given, the baby still needs to be burped. Neonates who are fed every 3 hours still need to be burped. CN: Health promotion and maintenance; CL: Evaluate

71. A primigravid adolescent client at approxi- mately 15 weeks' gestation who is visiting the prenatal clinic with her mother is to undergo alphafetoprotein (AFP) screening. When developing the teaching plan for this client, the nurse should include which of the following? ■ 1. Ultrasonography usually accompanies AFP testing. ■ 2. Results are usually very accurate until 20 weeks' gestation. ■ 3. A clean-catch midstream urine specimen is needed. ■ 4. Increased levels of AFP are associated with neural tube defects.

71. 4. Increased AFP levels are associated with neural tube defects, such as spina bifi da, anenceph- aly, and encephalocele. Ultrasonography is used to confi rm a neural tube defect only when AFP levels are increased. Because AFP levels are usually high- est at 15 to 18 weeks' gestation, this is the optimum time for testing. Performing the test after this time leads to inaccurate results. The client's blood, not urine, is used for the sample. CN: Reduction of risk potential; CL: Create

71. A mother is visiting her neonate in the neo- natal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do? ■ 1. Bring in toys for distraction. ■ 2. Place a musical mobile over the crib. ■ 3. Stroke the neonate's back. ■ 4. Use constant, gentle touch.

71. 4. Neonates that are sick do not have the physical resources or energy to respond to all ele- ments of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physi- cal support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands. CN: Basic care and comfort; CL: Synthesize

72. Which of the following statements best identifi es the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client? ■ 1. Pregnant adolescents are at high risk for pregnancy-induced hypertension. ■ 2. Gestational diabetes during pregnancy com- monly develops in adolescents. ■ 3. Adolescents need additional instruction related to common discomforts. ■ 4. The father of the baby is rarely involved in the pregnancy.

72. 1. Prenatal care is commonly the most criti- cal factor infl uencing pregnancy outcome. This is especially true for adolescents, because the most signifi cant medical complication in pregnant adolescents is pregnancy-induced hypertension. Continued prenatal care helps to allow for early detection and prompt intervention should the com- plication arise. Other risks for adolescents include low-birth-weight infant, preterm labor, iron-defi - ciency anemia, and cephalopelvic disproportion. Gestational diabetes can occur with any pregnancy regardless of the age of the mother. Generally, all fi rst-time mothers need instruction related to dis- comforts. Adolescent mothers have better nutrition when they attend group classes and are subject to peer pressure. No evidence demonstrates that most adolescents lack support systems. Fathers may abandon mothers at any time during the pregnancy; other fathers, regardless of age, are supportive throughout the pregnancy. CN: Health promotion and maintenance; CL: Apply

72. A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75%. The nurse should: ■ 1. Increase the I.V. rate. ■ 2. Provide supplemental oxygen. ■ 3. Record the fi nding on the chart and repeat the reading in 30 minutes. ■ 4. Wrap the neonate to increase body temperature.

72. 2. Recommended pulse oximetry reading in a full-term neonate is 95% to 100%. The satura- tion reading of only 75% is an indication that the neonate is not adequately oxygenating in room air. Providing supplemental oxygen will increase the neonate's oxygen saturation. Increasing the I.V. rate will not improve the oxygen saturation. Document- ing the fi nding and taking no action is not appro- priate with a saturation of 75%. Wrapping and increasing the body temperature of the neonate may increase the saturation reading only if it is inaccu- rate due to cold extremities. Caution must be used because overheating a neonate can be harmful. CN: Reduction of risk potential; CL: Synthesize .

72. Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 11⁄2 minutes. The uterine resting tone is greater than 20 mm mercury with a nonre- assuring fetal heart rate and pattern. Which of the following actions should the nurse take fi rst? ■ 1. Notify the health care provider. ■ 2. Turn off the oxytocin (Pitocin) infusion. ■ 3. Turn the client to her left side. ■ 4. Increase the maintenance I.V. fluids.

72. 2. The client is experiencing uterine hyper- stimulation from the oxytocin (Pitocin). The fi rst intervention should be to stop the oxytocin infu- sion, which may be the cause of the long, frequent contractions, elevated resting tone, and nonreassur- ing fetal heart patterns. Only after turning off the oxytocin, should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance I.V. fl uids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the health care provider. CN: Management of care; CL: Synthesize

72. After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching? ■ 1. "I can let the milk sit out in a bottle for up to 10 hours." ■ 2. "I'll be sure to label the milk with the date, time, and amount." ■ 3. "I can safely store the milk for 3 days in the refrigerator." ■ 4. "I can keep the milk in a deep-freeze in clean glass bottles for up to 1 year."

72. 3. Stored breast milk can be safely kept in the refrigerator for up to 7 days or in a deep-freeze at 0° F (-18° C) for 12 months. Breast milk should be stored in glass containers because immunoglobu- lin tends to stick to plastic bottles. Breast milk can remain without refrigeration or loss of nutrients for up to 10 hours. The containers should be labeled with date, time, and amount to prevent inadvertent administration of spoiled milk. Frozen breast milk should be thawed in the refrigerator for a few hours, placed under warm tap water, then shaken. CN: Health promotion and maintenance; CL: Evaluate

72. A primigravid client with class II heart dis- ease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low- sodium, 1,800-calorie diet. Which of the following instructions should the nurse give the client? ■ 1. Avoid folic acid supplements to prevent megaloblastic anemia. ■ 2. Severely restrict sodium intake throughout the pregnancy. ■ 3. Take iron supplements with milk to enhance absorption. ■ 4. Increase caloric intake to 2,200 calories daily to promote fetal growth.

72. 4. The client can continue a low-sodium diet but should increase the caloric intake to 2,200 calories daily to provide adequate nutrients to support fetal growth and development. Folic acid supplements, a standard component of care, are used to prevent folic acid defi ciency, which is associated with megaloblastic anemia during pregnancy. Severe restriction of sodium intake is not recommended be- cause sodium is necessary to maintain fl uid volume. Iron supplements should be taken with acidic foods and fl uids (e.g., citrus juices) for maximum absorp- tion. Milk decreases the absorption of iron. CN: Reduction of risk potential; CL: Apply

73. On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifi es the physi- cian immediately because of the possibility of: ■ 1. Ectopic pregnancy. ■ 2. Abruptio placentae. ■ 3. Gestational trophoblastic disease. ■ 4. Complete abortion.

73. 1. The client's signs and symptoms indicate a probable ectopic pregnancy, which can be confi rmed by ultrasound examination or by culdocentesis. The physician is notifi ed immediately because hypov- olemic shock may develop without external bleed- ing. Once the fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae would be manifested by a board-like uterus in the third trimester. Gestational trophoblas- tic disease would be suspected if the client exhib- ited no fetal heart rate and symptoms of pregnancy- induced hypertension before 20 weeks' gestation. A client with a complete abortion would exhibit a normal pulse and blood pressure with scant vaginal bleeding. CN: Physiological adaptation; CL: Analyze

73. Which of the following would be included in the teaching plan about pregnancy-related breast changes for a primigravid client? ■ 1. Growth of the milk ducts is greatest during the fi rst 8 weeks of gestation. ■ 2. Enlargement of the breasts indicates adequate levels of progesterone. ■ 3. Colostrum is usually secreted by about the 16th week of gestation. ■ 4. Darkening of the areola occurs during the last month of pregnancy.

73. 3. Colostrum is usually secreted by about the 16th week of gestation in preparation for breast-feeding. Growth of the milk ducts is great- est in the last trimester, not in the fi rst 8 weeks of gestation. Enlargement of the breasts is usually caused by estrogen, not progesterone. Darkening of the areola can occur as early as the sixth week of gestation. CN: Health promotion and maintenance; CL: Create

73. A client is induced with oxytocin (Pitocin). The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this fi nding should the nurse take? ■ 1. Turn the client to her left side. ■ 2. Administer oxygen via facemask at 10 to 12 L/minute. ■ 3. Notify the health care provider of the situation. ■ 4. Document fetal well-being.

73. 4. Accelerations that are episodic and occur during fetal movement demonstrate fetal well-being. Turning the client to the left side, applying oxygen by face mask and notifying the health care provider are interventions used for late and variable decelera- tions indicating the fetus is not tolerating the induc- tion process well. CN: Physiological adaptation; CL: Synthesize

73. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following? ■ 1. Adrenalin. ■ 2. Estrogen. ■ 3. Prolactin. ■ 4. Oxytocin.

73. 4. Oxytocin stimulates the let-down refl ex when milk is carried to the nipples. A lactating mother can experience the let-down refl ex suddenly when she hears her baby cry or when she antici- pates a feeding. Some mothers have reported feeling the let-down refl ex just by thinking about the baby. Adrenalin may increase if the mother is excited, but this hormone has no direct infl uence on breast- feeding. Estrogen infl uences development of female secondary sex characteristics and controls menstrua- tion. Prolactin stimulates milk production. CN: Health promotion and maintenance; CL: Apply

74. The nurse is assessing a multigravida client at 12 weeks' gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which of the following should the nurse obtain about the client's history? Select all that apply. ■ 1. History of sexually transmitted infections. ■ 2. Number of sexual partners. ■ 3. Last menstrual period. ■ 4. Cesarean section. ■ 5. IUD use. ■ 6. Contraceptive use.

74. 1, 2, 3, 5, 6. The client may be experienc- ing an ectopic pregnancy. Contributing factors to an ectopic pregnancy include a prior history of sexually transmitted infection which can scar the fallopian tubes. Prior use of an IUD as contracep- tion with multiple sex partners increases the risk of sexually transmitted infections. Knowledge of the client's last menstrual period and contraceptive use may support or rule out the possibility of an ectopic pregnancy. The client's history of cesarean sections would not contribute information valuable to the client's current situation or potential diagnosis of ectopic pregnancy. CN: Reduction of risk potential; CL: Analyze

74. As a nurse begins her shift on the obstetrical unit, there are several new admissions. The client with which of the following conditions would be a candidate for induction? ■ 1. Pregnancy-induced hypertension (PIH). ■ 2. Active herpes. ■ 3. Face presentation. ■ 4. Fetus with late decelerations.

74. 1. The client with PIH would be a candidate for the induction process because ending the preg- nancy is the only way to cure PIH. A client with active herpes would be a candidate for a cesarean section to prevent the fetus from contracting the virus while passing through the birth canal. The woman with a face presentation will not be able to deliver vaginally due to the extended position of the neck. The client whose fetus exhibits late decelerations without oxytocin (Pitocin) would be at greater risk for fetal distress with use of this drug. Late decelerations indicate the fetus does not have enough placental reserves to remain oxygen- ated during the entire contraction. This client may require a cesarean section. CN: Management of care; CL: Evaluate

74. A primigravid client at 32 weeks' gestation is enrolled in a breast-feeding class. Which of the fol- lowing statements indicate that the client understands the breast-feeding education? Select all that apply. ■ 1. "My milk supply will be adequate since I have increased a whole bra size during pregnancy." ■ 2. "I can hold my baby several different ways during feedings." ■ 3. "If my infant latches on properly, I won't develop mastitis." ■ 4. "If I breast-feed, my uterus will return to prepregnancy size more quickly." ■ 5. "Breast milk can be expressed and stored at room temperature since it is natural." ■ 6. "I need to feed my baby when I see feeding cues and not wait until she is crying."

74. 2, 4, 6. Understanding of breast-feeding educa- tion is demonstrated by statements involving knowl- edge of the several positions available for comfortable breast-feeding, oxytocin release from the pituitary leading to a let-down refl ex and uterine contractions for involution, and feeding cues helpful in success- ful breast-feeding (because waiting until the infant is hungry and crying is stressful). Breast size does not ensure successful breast-feeding. Mastitis is an infec- tious process and is not infl uenced by latching on. Breast milk needs to be stored in the refrigerator or freezer to decrease the risk of bacterial growth. CN: Basic care and comfort; CL: Evaluate

75. A breast-feeding primiparous client who delivered 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake? ■ 1. Six to eight wet diapers by the fi fth day. ■ 2. Three to four transitional stools on the fourth day. ■ 3. Ability to fall asleep easily after feeding on the fi rst day. ■ 4. Regain of lost birth weight by the third day.

75. 1. The nurse should instruct the client that the baby is getting enough to eat when there are six to eight wet diapers by the fi fth day of age. Other signs include good suckling sounds during feeding, dripping breast milk at the mouth, and quiet rest or sleep after the feeding. By the fourth day of age, the infant should have soft yellow stools, not transitional (greenish) stools. Falling asleep easily after feeding on the fi rst day is not a good indicator because most infants are sleepy during the fi rst 24 hours. Most infants regain their lost birth weight in 7 to 10 days after birth. An infant who has gained weight during the fi rst well-baby checkup (usually at 2 weeks) is getting suffi cient breast milk at feedings. CN: Health promotion and maintenance; CL: Apply

74. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following? ■ 1. Apply an ice cube to the nipples. ■ 2. Rub her nipples gently with lanolin cream. ■ 3. Express a small amount of breast milk. ■ 4. Offer the neonate a small amount of formula.

74. 3. Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk fl ow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorge- ment. However, it may temporarily relieve the discomfort associated with breast engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary. Use of lanolin may cause sensitivity and irritation. Having fre- quent breast-feeding sessions, rather than offer- ing the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion. CN: Health promotion and maintenance; CL: Apply

74. A neonate with heart failure is being dis- charged home. In teaching the parents about the neo- nate's nutritional needs, the nurse should explain that: ■ 1. Fluids should be restricted. ■ 2. Decreased activity level should reduce the need for additional calories. ■ 3. The formula should be low in sodium. ■ 4. The neonate may need a formula with higher calories per fl uid ounce.

74. 4. Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fl uid intake will decrease calories needed for growth. These neo- nates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growth and development. The sodium level should be at a normal level to ensure adequate fl uid and electrolyte balance unless prescribed by the physician. CN: Health promotion and maintenance; CL: Create

75. During an assessment of a neonate born at 33 weeks' gestation, a nurse fi nds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indo- methacin. An expected outcome after the admin- istration of indomethacin to a neonate with patent ductus arteriosis is: ■ 1. Closure of a patent ductus arteriosus. ■ 2. Decreased bleeding time. ■ 3. Increased gastrointestinal function. ■ 4. Increased renal output.

75. 1. The indication for the use of indometha- cin is to close a patent ductus arteriosus. Adverse effects include decreased renal blood fl ow, platelet dysfunction with coagulation defects, decreased GI motility, and an increase in necrotizing enterocoli- tis. Thus, increased bleeding time, decreased gas- trointestinal function, and decreased renal output would be expected outcomes after the administra- tion of indomethacin. CN: Pharmacological and parenteral therapies; CL: Evaluate

75. When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? ■ 1. The temperature decreases slightly early in pregnancy. ■ 2. Cardiac output increases by 25% to 50% dur- ing pregnancy. ■ 3. The circulating fi brinogen level decreases as much as 50% during pregnancy. ■ 4. The anterior pituitary gland secretes oxytocin late in pregnancy.

75. 2. During pregnancy, the circulatory system undergoes tremendous changes. Cardiac output increases by 25% to 50%, and circulatory blood volume increases by about 30%. The client may ex- perience transient hypotension and dizziness with sudden position changes. Early in pregnancy there is a slight increase in the temperature, and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fi brinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported, because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Brax- ton Hicks contractions or early labor symptoms. CN: Health promotion and maintenance; CL: Create

75. Before surgery to remove an ectopic preg- nancy and the fallopian tube, which of the follow- ing would alert the nurse to the possibility of tubal rupture? ■ 1. Amount of vaginal bleeding and discharge. ■ 2. Falling hematocrit and hemoglobin levels. ■ 3. Slow, bounding pulse rate of 80 bpm. ■ 4. Marked abdominal edema.

75. 2. Falling hematocrit and hemoglobin levels indicate shock, which occurs if the tube ruptures. Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain and referred shoulder pain. The amount of vaginal bleeding that is evident is a poor estimate of ac- tual blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse. Abdomi- nal edema is a late sign of a tubal rupture in ectopic pregnancy. CN: Reduction of risk potential; CL: Analyze

75. A nurse and an LPN are working in the labor and delivery unit. Of the following assessments and interventions that must be done immediately, which should the nurse assign to the LPN? ■ 1. Complete an initial assessment on a client. ■ 2. Increase the oxytocin (Pitocin) rate on a labor- ing client. ■ 3. Perform a straight catheterization for protein analysis. ■ 4. Assess a laboring client for a change in labor pattern.

75. 3. The straight catheterization is within the scope of practice of a licensed practical nurse. An initial or continuing assessment is the responsibil- ity of the registered nurse. Assessment must be complete before increasing the I.V. rate of Pitocin. The assessment and the increase in Pitocin rate are responsibilities for the nurse. CN: Management of care; CL: Evaluate

76. Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? ■ 1. "Wait until you have breast-fed for at least 4 months." ■ 2. "Eliminate the baby's favorite feeding times fi rst." ■ 3. "Plan to omit the daytime feedings last." ■ 4. "Gradually eliminate one feeding at a time."

76. 4. The client should wean the infant gradu- ally, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the mother desires; she does not have to breast-feed for 4 months. Most infants (and mothers) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy. CN: Health promotion and maintenance; CL: Create

76. When teaching a primigravid client at 24 weeks' gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include? ■ 1. A fetal biophysical profi le involves assess- ments of breathing movements, body move- ments, tone, amniotic fl uid volume, and fetal heart rate reactivity. ■ 2. A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography. ■ 3. Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks' gestation. ■ 4. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample.

76. 1. The fetal biophysical profi le includes fetal breathing movements, fetal body movements, tone, amniotic fl uid volume, and fetal heart rate reactivity. A reactive nonstress test is a sign of fetal well-being and does not require further evaluation. A nonreactive nonstress test requires further evaluation. A contrac- tion stress test or oxytocin challenge test should be performed only on women who are at risk for fetal dis- tress during labor. The contraction stress test is rarely performed before 28 weeks' gestation because of the possibility of initiating labor. Percutaneous umbili- cal cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood sample. CN: Reduction of risk potential; CL: Apply

76. A nurse and a nursing assistant are caring for clients in a labor and delivery unit. Which task should the registered nurse assign to the nursing assistant? ■ 1. Perform a fundal check on a 2-day postpar- tum client. ■ 2. Remove a fetal monitor and assist a client to the bathroom. ■ 3. Give ibuprofen 800 mg by mouth to a newly delivered client. ■ 4. Teach a new mother how to bottle-feed her infant.

76. 2. Removing a fetal monitor from a client and assisting her to the bathroom are within the realm of practice of a nursing assistant. Performing a fundal check is an assessment, which is a responsibility of a registered nurse. A nursing assistant is not permit- ted to administer medication by any route. Educa- tion is also part of the professional nursing role. Although a nursing assistant can assist a mother with bottle feeding, the formal client education must be completed and validated by the nurse. CN: Management of care; CL: Evaluate

76. A multigravid client diagnosed with a prob- able ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess? ■ 1. Uterine cramping. ■ 2. Abdominal distention. ■ 3. Hemoglobin and hematocrit. ■ 4. Pulse rate.

76. 4. Fallopian tube rupture is an emergency situation because of extensive bleeding into the peri- toneal cavity. Shock soon develops if precautionary measures are not taken. The nurse readying a client for surgery should be especially careful to monitor blood pressure and pulse rate for signs of impending shock. The nurse should be prepared to administer fl uids, blood, or plasma expanders as necessary through an intravenous line that should already be in place. Because the fertilized ovum has implanted outside the uterus, uterine cramping is unlikely. However, abdominal tenderness or knife-like pain may occur. Abdominal fullness may be present, but abdominal distention is rare unless peritonitis has developed. Although the hemoglobin and hemat- ocrit may be checked routinely before surgery, the laboratory results may not truly refl ect the presence or degree of acute hemorrhage. CN: Reduction of risk potential; CL: Analyze

77. A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neo- nate is to: ■ 1. Assess vital signs including blood pressure every hour. ■ 2. Minimize environmental stimuli. ■ 3. Place the infant in a well-lighted area for observation. ■ 4. Provide stimulation to increase adaptation to the environment.

77. 2. A quiet environment with decreased stimulation is the best treatment for a drug-exposed neonate. The drug-exposed neonate has limited ability to deal with stress and cope with stimuli. Assessing vital signs with blood pressure every hour will disturb the neonate's rest periods and cause increased physical and psychological demands. Placement in a well-lighted or stimulating environ- ment is overwhelming for the neonate and will increase the neonate's stress level. CN: Physiological adaptation; CL: Apply

77. A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic preg- nancy. When obtaining the client's history, which of the following would be most important to identify as a predisposing factor? ■ 1. Urinary tract infection. ■ 2. Marijuana use during pregnancy. ■ 3. Episodes of pelvic infl ammatory disease. ■ 4. Use of estrogen-progestin contraceptives.

77. 3. Anything that causes a narrowing or con- striction in the fallopian tubes so that a fertilized ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy. Pelvic infl ammatory disease is the most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic pregnancy is not related to urinary tract infections. Use of marijuana during pregnancy is not associated with ectopic pregnancy, but its use can result in cognitive reduction if the mother's use during pregnancy is extensive. Progestin-only contraceptives and intra- uterine devices have been associated with ectopic pregnancy. CN: Physiological adaptation; CL: Analyze

77. When teaching a primigravid client how to do Kegel exercises, the nurse explains that the expected outcome of these exercises is to: ■ 1. Prevent vulvar edema. ■ 2. Alleviate lower back discomfort. ■ 3. Strengthen the perineal muscles. ■ 4. Strengthen the abdominal muscles.

77. 3. The purpose of Kegel exercises is to strengthen the perineal muscles in preparation for the labor process. These movements strengthen the pubococcygeal muscle, which surrounds the uri- nary meatus and vagina. No evidence is available to support the idea that these exercises prevent vulvar edema, alleviate lower back discomfort, or strength- en the abdominal muscles. CN: Basic care and comfort; CL: Apply

77. A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examina- tion, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery? ■ 1. The fetal monitor strip shows late decelerations. ■ 2. The client begins to speak to her family in her native language. ■ 3. The fetal monitor strip shows early decelerations. ■ 4. The client's facial expressions become animated.

77. 3. When the fetal head is compressed, early decelerations are seen as a vagal response occurs and the fetal heart rate decelerates and inversely mirrors the contraction. This response commonly occurs when the client is 9 to 10 cm dilated or push- ing. If communication cannot be facilitated, early decelerations are one indicator that delivery may be approaching. Late decelerations may occur at this time but indicate uteroplacental insuffi ciency rather than imminent birth. At any time during the labor process, the client may communicate with her fam- ily in her native language. The client's facial expres- sions may change at any point during labor and cannot be used as an indicator of imminent delivery. CN: Physiological adaptation; CL: Analyze

77. Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she's crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which of the following? ■ 1. Lack of adequate intake to meet maternal nutritional needs. ■ 2. The mother's fears about the baby's weight gain. ■ 3. Preventing the neonate from sucking long enough with each feeding. ■ 4. The neonate's temporary growth spurt, which requires more feedings.

77. 4. Neonates normally increase breast-feeding during periods of rapid growth (growth spurts). These can be expected at age 10 to 14 days, 5 to 6 weeks, 2.5 to 3 months, and 4.5 to 6 months. Each growth spurt is usually followed by a regular feeding pattern. Lack of adequate intake to meet maternal nutritional needs is not associated with the neonate's desire for more frequent breast-feeding sessions. However, an intake of adequate calories is necessary to produce quality breast milk. The mother's fears about weight gain and preventing the neonate from sucking long enough are not associated with the desire for more frequent breast-feeding sessions. CN: Health promotion and maintenance; CL: Analyze

The Intrapartal Client with Risk Factors 78. A client is admitted with a suspected abrup- tio placentae. The nurse should assess the client for which of the following signs and symptoms? Select all that apply. ■ 1. Bleeding that is concealed or apparent. ■ 2. Abdominal rigidity. ■ 3. Painful abdomen. ■ 4. Painless bleeding. ■ 5. Large placenta. ■ 6. Bleeding that stops spontaneously.

78. 1, 2, 3. With abruptio placentae, bleeding may occur vaginally, may be obstructed by the fetal head, or it may be hidden behind a portion of the placenta. Abdominal rigidity occurs, particularly with a con- cealed hemorrhage because the girth and fundal height increase. Abdominal pain is one of the classic symptoms of abruption. The pain may be intermittent, as in labor contractions, or continuous. The placenta with abruption is not larger than a normal placenta and the bleeding does not end spontaneously. CN: Physiological adaptation; CL: Analyze

78. The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should: ■ 1. Write down the results, read back the results to the caller from the laboratory, and receive confi rmation from the caller that the nurse understands the results. ■ 2. Repeat the results to the caller from the laboratory, write the results on scrap paper fi rst, and then transfer the results to the chart. ■ 3. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery. ■ 4. Request that the laboratory send the results by e-mail to transfer to the client's electronic record.

78. 1. To ensure client safety, the nurse should fi rst write the results on the chart, then read them back to the caller and wait for the caller to confi rm that the nurse has understood the results. Using a scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's electronic record is appro- priate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues. CN: Safety and infection control; CL: Apply

78. During a home visit to a breast-feeding prim- iparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do? ■ 1. Wipe off any lanolin creams from the nipple before each feeding. ■ 2. Position the baby with the entire areola in the baby's mouth. ■ 3. Feed the baby less often for the next several days. ■ 4. Use a mild soap while in the shower to pre- vent an infection.

78. 2. Even if the nipples are sore and cracked, the mother should position the baby with the entire areola in the baby's mouth so that the nipple is not compressed between the baby's gums during feeding. The best method is to prevent cracked nipples before they occur. This can be done by feeding frequently and using proper positioning. Warm, moist tea bags can soothe cracked nipples because of tannic acid in the tea. Creams on the nipples should be avoided; wiping off any lanolin creams from the nipple before each feeding can cause further soreness. Feeding the baby less often for the next few days will cause engorgement (and possible neonatal weight loss), leading to additional problems. Soap use while in the shower should be avoided to prevent drying and removal of protective oils. CN: Reduction of risk potential; CL: Synthesize

78. After surgery to remove a ruptured fallopian tube, a multigravid client receives discharge instructions about potential complications to report to her physi- cian. Which of the following, if stated by the client as a complication, indicates a need for additional teaching? ■ 1. Pain. ■ 2. Headache. ■ 3. Fever. ■ 4. Bleeding.

78. 2. The client should not experience a head- ache or dizziness. Symptoms that the client should report include pain (caused by stretching of the tube), temperature elevation (suggesting infection), and bleeding (suggesting hemorrhage). The client should also be instructed that infertility may occur as a result of the removal of one fallopian tube. CN: Reduction of risk potential; CL: Evaluate

78. During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks' gestation and is now in her third trimes- ter states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." The nurse should tell the mother: ■ 1. "Dreams like the ones that you describe are very unusual. Please tell me more about them." ■ 2. "Commonly when a mother has these dreams, she is trying to cope with becoming a parent." ■ 3. "Dreams about the baby late in pregnancy usually mean that labor is about to begin soon." ■ 4. "It's not uncommon to have dreams about the baby, particularly in the third trimester."

78. 4. During the third trimester, it is not uncom- mon for clients to have dreams or fantasies about the baby. Sometimes the dreams are about infants who are malformed or, in this example, covered with hair. There is no evidence to suggest that the client is trying to cope with becoming a parent. Having dreams about the baby does not mean that labor will begin soon. CN: Psychosocial adaptation; CL: Synthesize

The Postpartal Client Who Bottle-Feeds 79. The nurse is assessing a client at her postpar- tum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client fi nd- ing indicates a problem at this time? ■ 1. Firm fundus at the symphysis. ■ 2. White, thick vaginal discharge. ■ 3. Striae that are silver in color. ■ 4. Soft breasts without milk.

79. 1. By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a non- pregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associ- ated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother). CN: Physiological adaptation; CL: Analyze

79. A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following? ■ 1. Pregnancy-induced hypertension. ■ 2. Urinary tract infection. ■ 3. Chorioamnionitis. ■ 4. Precipitous delivery.

79. 1. Clients who are pregnant with two (or more) fetuses are at greater risk for pregnancy-induced hypertension, hydramnios, placenta previa, preterm labor, and anemia. During delivery, occasionally the placenta of the second twin separates before that twin is delivered, causing profound bleeding. Urinary tract infections and chorioamnionitis are not more com- mon in clients with multifetal gestation compared with women with single-fetus pregnancies. Although multiparous women frequently deliver more quickly than a nullipara does, precipitous delivery is not more common with twin gestations. CN: Reduction of risk potential; CL: Analyze

79. A primigravid client at 36 weeks' gesta- tion tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the follow- ing suggestions would be most helpful? ■ 1. Practice relaxation techniques before bedtime. ■ 2. Drink a cup of hot chocolate before bedtime. ■ 3. Drink a small glass of wine with dinner. ■ 4. Exercise for 30 minutes just before bedtime.

79. 1. Insomnia in the later part of pregnancy is not uncommon because the client has diffi culty getting into a position of comfort. This is further compounded by frequent nocturia. The best sug- gestion would be to advise the client to practice relaxation techniques before bedtime. The client should avoid caffeine products such as chocolate and coffee before going to bed because caffeine is a stimulant. Alcohol consumption, regardless of the type or amount, should be avoided. Exercise is advised during the day, but it should be avoided before bedtime because exercise can stimulate the client and decrease the client's ability to fall asleep. CN: Basic care and comfort; CL: Apply

79. A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse antic- ipates that, because the client's fallopian tube has not yet ruptured, which of the following may be ordered? ■ 1. Progestin contraceptives (Hylutin). ■ 2. Medroxyprogesterone (Depo-Provera). ■ 3. Methotrexate. ■ 4. Dyphylline (Dilor).

79. 3. Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by leucovorin. This chemotherapeutic agent attacks the fast-growing zygote and trophoblast cells. RU-486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine whether the tube is still patent. Progestin-only contraceptives and medroxyprogesterone are ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used. CN: Pharmacological and parenteral therapies; CL: Analyze

79. A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which of the following responses by the nurse would be most appropriate? ■ 1. "You are Rh-positive and the neonate's father is Rh-negative." ■ 2. "You and the neonate's father are both Rh- negative." ■ 3. "You are Rh-negative and the neonate's father is Rh-positive." ■ 4. "The fetus is Rh-negative and you are Rh- positive."

79. 3. Hemolytic disease of the newborn is associ- ated with Rh problems. Hemolytic disease of the newborn occurs most commonly when the mother is Rh-negative and the father is Rh-positive. About 13% of white Americans, 7% to 8% of African Ameri- cans, and 1% of Asian Americans are Rh- negative. Rh-positive cells enter the mother's Rh-negative bloodstream, and antibodies to the Rh- positive cells are produced. In a subsequent pregnancy, the anti- bodies cross the placenta to the Rh-positive fetus and begin the destruction of Rh-positive cells through hemolysis. This results in severe fetal anemia. CN: Physiological adaptation; CL: Apply

8. Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? ■ 1. Anemia. ■ 2. Hypertension. ■ 3. Dysmenorrhea. ■ 4. Acne vulgaris.

8. 2. Before advising a client about oral con- traceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addi- tion, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-defi ciency anemia, dysmenorrhea, and acne are not contrain- dications for the use of oral contraceptives. Iron- defi ciency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual fl ow and thus decrease the amount of iron lost through menses, thereby providing a benefi cial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be ef- fective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contracep- tives commonly improves facial acne. CN: Reduction of risk potential; CL: Analyze

81. After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following? ■ 1. Cardiac decompensation. ■ 2. Polycythemia. ■ 3. Anemia. ■ 4. Splenic enlargement.

81. 2. The Rh-sensitized neonate generally does not have problems related to polycythemia. There- fore, the client needs additional teaching. In gen- eral, moderate to severe Rh sensitization can cause anemia, enlarged spleen, and cardiac decompensa- tion. Cardiac decompensation (as in heart failure) occurs because of severe anemia. Anemia is caused by the destruction of red blood cells by antibodies as the severity of hemolytic disease of the neonate increases. Splenic enlargement is caused by the excessive destruction of fetal red blood cells. CN: Physiological adaptation; CL: Evaluate

8. The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication? ■ 1. Resting period of 2 minutes between contractions. ■ 2. Normal patellar and elbow refl exes for the past 2 hours. ■ 3. Softening of the cervix and beginning effacement. ■ 4. Leaking of clear amniotic fl uid in small amounts.

8. 3. Prostaglandin gel may be used for cervical ripening before the induction of labor with oxytocin. It is usually administered by catheter or suppository, or by vaginal insertion. Two to three doses are usu- ally needed to begin the softening process. Common adverse effects include nausea, vomiting, fever, and diarrhea. Continuous fetal heart rate monitoring and close monitoring of maternal vital signs are neces- sary to detect subtle changes or adverse effects. Prostaglandin gel usually does not initiate contrac- tions; therefore, the rest period between contractions will be greater than 2 minutes. There is no need to assess refl exes based on prostaglandin use. Leaking of amniotic fl uid is not caused by the use of this gel. CN: Pharmacological and parenteral therapies; CL: Evaluate

8. In response to the nurse's question about how she is feeling, a postpartum client states that she is fi ne. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? ■ 1. Taking in. ■ 2. Taking on. ■ 3. Taking hold. ■ 4. Letting go.

8. 3. The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfi lling infant care and needs. The tak- ing in phase is the fi rst period after delivery where there is emphasis on reviewing and reliving the labor and delivery process, concern with self and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individu- als assume care of the infant and begins the separa- tion process. CN: Psychosocial adaptation; CL: Analyze

8. When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse iden- tify as the most appropriate client-centered goal? ■ 1. Return visit to the prenatal clinic in approxi- mately 4 weeks. ■ 2. Decreased edema after 1 week of a low- protein, low-fi ber diet. ■ 3. Bed rest on the left side during the day, with bathroom privileges. ■ 4. Immediate reporting of adverse reactions to magnesium sulfate therapy.

8. 3. The client with mild preeclampsia is com- monly treated at home with activity restriction. Bed rest for most of the day with the client lying in the left lateral recumbent position is recommended. This position helps to decrease pressure on the vena cava, thus increasing venous return, circula- tory volume, and renal and placental perfusion. A decrease in angiotensin II improves renal blood fl ow, lowers blood pressure, and increases diuresis. Typically, the client is monitored with home visits twice a week. The client usually returns to the clinic every 2 weeks until 36 weeks' gestation. After that time, clinic visits occur at least every week or more often, if needed. The client's diet needs to be well balanced, with ample protein intake. Fiber intake may need to be increased to prevent complications from prolonged bed rest, such as constipation. If magnesium sulfate is necessary, as in severe preec- lampsia, the drug is usually administered intra- venously, and the client is carefully monitored in the hospital setting because of the possible risk of seizure activity. CN: Physiological adaptation; CL: Analysis

80. Which of the following client statements indicates a need for additional teaching about self- care during pregnancy? ■ 1. "I should use nonskid pads when I take a shower or bath." ■ 2. "I should avoid using soap on my nipples to prevent drying." ■ 3. "I should sit in a hot tub for 20 minutes to relax after working." ■ 4. "I should avoid douching even if my vaginal secretions increase."

80. 3. The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the fi rst trimes- ter, because their use can lead to maternal hyper- thermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of grav- ity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal fl ora and increase the client's risk of infection. CN: Health promotion and maintenance; CL: Evaluate

80. After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which of the follow- ing client statements indicates the need for addi- tional teaching? ■ 1. "I'll eat dry crackers or toast before arising in the morning." ■ 2. "I'll drink adequate fl uids separate from my meals or snacks." ■ 3. "I'll eat two large meals daily with frequent protein snacks." ■ 4. "I'll snack on a small amount of carbohy- drates throughout the day."

80. 3. The client needs further instructions when she says she should eat two meals a day with frequent protein snacks to decrease nausea and vomiting. The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting. Eating dry crackers or toast before arising, consuming fl uids separately from meals, and avoiding greasy or spicy foods may also help to decrease nausea and vomiting. CN: Basic care and comfort; CL: Evaluate

80. A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following? ■ 1. Breathe slowly after each contraction. ■ 2. Avoid the use of analgesics for the labor pain. ■ 3. Remain in a side-lying position with the head elevated. ■ 4. Request local anesthesia for vaginal delivery.

80. 3. The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophy- lactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discom- fort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor. CN: Reduction of risk potential; CL: Synthesize

80. After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitiza- tion, the nurse determines that the client under- stands why she was not sensitized during her other pregnancy when she says which of the following? ■ 1. "My other baby had a different father." ■ 2. "Like most women, I have immunity against the Rh factor." ■ 3. "Antibodies are not usually formed until after exposure to an antigen." ■ 4. "My blood couldn't neutralize antibodies formed from my first pregnancy."

80. 3. The problem of Rh sensitivity arises when the mother's blood develops antibodies after fetal red blood cells enter the maternal circulation. In cases of Rh sensitivity, this usually does not occur until after the fi rst pregnancy. Hence, hemolytic disease of the newborn is rare in a primiparous cli- ent. A mismatched blood transfusion in the past or an unrecognized spontaneous abortion could also result in hemolytic disease because the transfusion or abortion would have the same effects on the cli- ent. The statement about the other baby having a different father may be true. However, if both fathers were Rh-positive, then sensitization could occur. Most women do not have immunity against the antibodies formed when Rh-positive cells enter the mother's bloodstream. Antibodies are not neutral- ized by the mother's system. CN: Reduction of risk potential; CL: Evaluate

80. A client delivered 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indi- cates that the nurse should reinforce the instructions to the client? ■ 1. "I will wear a sports bra or a well fi tting bra for several days." ■ 2. "When showering, I'll direct water onto my shoulders." ■ 3. "I will only use only water to clean my nipples." ■ 4. "I will use a breast pump to remove any milk that may appear."

80. 4. The use of a breast pump to remove milk is contraindicated in bottle-feeding mothers. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk produc- tion. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fi tting provides support and decreases stimu- lation. (Binders are not suggested.) Having the water in a shower land on the shoulders of the mother rather than the breasts also decreases stimulation. Only water is necessary to clean nipples when breast or bottle-feeding.

81. A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that "she has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which of the following? ■ 1. Hypercalcemia. ■ 2. Hypobilirubinemia. ■ 3. Hypokalemia. ■ 4. Hyperglycemia.

81. 3. Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspi- ration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocal- cemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyper- emesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fl uids, decreased metabolism of nutrients, and excessive vomiting. CN: Reduction of risk potential; CL: Analyze

81. To obtain the obstetric conjugate measurement, the nurse would do which of the following? ■ 1. Add 1.5 cm to the transverse diameter. ■ 2. First measure the angle of the pubic arch. ■ 3. Subtract 1.5 to 2 cm from the diagonal conju- gate. ■ 4. Measure the diameter of the pelvic inlet.

81. 3. The obstetric conjugate can be estimated by subtracting 1.5 to 2 cm from the diagonal conju- gate, which can be measured during a pelvic exami- nation. Transverse diameters of the pelvic inlet are not measured and the pubic arch has no relevance to the obstetrical conjugate. CN: Health promotion and maintenance; CL: Apply

81. When developing the plan of care for a mul- tigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently? ■ 1. Dehydration. ■ 2. Nausea and vomiting. ■ 3. Iron-defi ciency anemia. ■ 4. Tachycardia.

81. 4. Assessing for signs and symptoms asso- ciated with cardiac decompensation is the prior- ity. Class III heart disease during pregnancy has a 25% to 50% mortality. These clients are markedly compromised, with marked limitation of physical activity. They frequently experience fatigue, palpita- tions, dyspnea, or anginal pain. A pulse rate greater than 100 bpm or a respiratory rate greater than 25 breaths/minute may indicate cardiac decompensa- tion that could result in cardiac arrest. Additional symptoms include dyspnea, peripheral edema, orthopnea, tachypnea, rales, and hemoptysis. CN: Reduction of risk potential; CL: Analyze

81. A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift? ■ 1. Gravida, term, preterm, abortion, living. ■ 2. Cervical effacement, dilation, station. ■ 3. Support person with the client. ■ 4. Bottle- or breast-feeding preference.

81. 4. The bottle- or breast-feeding preference is the least important information to be reported to the oncoming shift. The bottle- or breast-feeding plans will be important after delivery as many mothers breast-feed within an hour after delivery. The cli- ent's obstetrical history is a higher priority because it provides information about previous birthing experience. Information on cervical effacement, dilation, and station indicates the current state of labor and is essential for planning continuity of care for this client. Nurses on the incoming shift should also know the extent of support the client will need and who is currently providing that support. CN: Physiological adaptation; CL: Create

82. A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravi- darum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which of the following hormones? ■ 1. Progesterone. ■ 2. Estrogen. ■ 3. Somatotropin. ■ 4. Aldosterone.

82. 2. Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotrophin production. Hyperemesis is also associated with infectious con- ditions, such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole. Progesterone is a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone. CN: Physiological adaptation; CL: Apply

82. A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should antici- pate that the physician most likely will order which of the following medications? ■ 1. Anticoagulants. ■ 2. Antibiotics. ■ 3. Diuretics. ■ 4. Folic acid supplements.

82. 2. Clients who have been diagnosed with class II heart disease and prosthetic valve replace- ment are most likely to have an order for antibiotic medications to prevent the development of bacterial endocarditis and bacteremia. Clients with valvular heart disease have a high susceptibility to subacute bacterial endocarditis. Anticoagulant therapy is usu- ally discontinued during labor and delivery because of the potential for hemorrhage. Diuretic medica- tions are generally not prescribed for clients with class I or class II heart disease. Diuretics usually are not necessary and may result in potassium deple- tion. Folic acid supplements are usually prescribed for clients with megaloblastic anemia. Folic acid is also included in many prenatal vitamins and can help to prevent neural tube defects in the fetus. CN: Pharmacological and parenteral therapies; CL: Synthesize

82. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. ■ 1. Differentiating the fetus from the self. ■ 2. Ambivalence concerning pregnancy. ■ 3. Experimenting with mothering roles. ■ 4. Realignment of roles and tasks. ■ 5. Trying various caregiver roles. ■ 6. Concern about labor and delivery.

82. 3, 4, 5, 6. During the third trimester of preg- nancy, the woman experiments with maternal and caregiver roles and may make plans for changes in employment, managing household tasks, and/ or childcare. The woman is also concerned about safety and passage through labor and delivery.. Other psychological tasks include preparation of the nursery, being tired of the pregnancy, and being introspective. A woman will begin to see herself as someone different from the fetus in the second trimester. Additionally, the mother may fantasize about the infant during the second trimester and be concerned about her changing body image. She may experience ambivalence about pregnancy in the fi rst trimester. CN: Psychosocial adaptation; CL: Create

82. After delivery, a direct Coombs test is per- formed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh- negative blood. The nurse explains to the client that this test is done to detect which of the following? ■ 1. Degree of anemia in the neonate. ■ 2. Electrolyte imbalances in the neonate. ■ 3. Antibodies coating the neonate's red blood cells. ■ 4. Antigens coating the neonate's red blood cells.

82. 3. A direct Coombs test is done on umbilical cord blood to detect antibodies coating the neonate's red blood cells. Hematocrit is used to detect anemia. Sodium, potassium, and chloride are used to detect electrolyte imbalances. Antigens on the neonate's red blood cells are proteins that help determine the neonate's blood type. CN: Reduction of risk potential; CL: Apply

83. A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dino- prostone) for the client. Before administering pros- taglandin E2 gel to the client, which of the following should the nurse do fi rst? ■ 1. Assess the frequency of uterine contractions. ■ 2. Place the client in a side-lying position. ■ 3. Determine whether the membranes have rup- tured. ■ 4. Prepare the client for an amniotomy.

83. 1. Before administering prostaglandin E2 gel, the nurse would assess the frequency and duration of any uterine contractions fi rst, because prostaglan- din E2 gel is contraindicated if the client is having contractions. If there are no contractions, the cli- ent should be placed in a semi-Fowler's position to allow for vaginal insertion of the gel. Although determining whether the client's membranes have ruptured is part of the assessment of any client in labor, it is not specifi cally related to the adminis- tration of prostaglandin E2 gel. If the membranes remain intact, an amniotomy may be performed once the client begins to dilate and the fetal head is engaged. However, it is not necessary for the nurse to prepare the client for this procedure at this time. CN: Pharmacological and parenteral therapies; CL: Synthesize

83. A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following? ■ 1. An immature cardiac sphincter. ■ 2. A defect in the gastrointestinal system. ■ 3. Burping the infant too frequently. ■ 4. Moving the infant during the feeding.

83. 1. Initial regurgitation in the neonate during the fi rst 12 to 24 hours may be caused by excessive mucus and gastric irritation from foreign substances in the stomach. After the fi rst 24 hours, regurgita- tion is thought to be caused by the neonate's imma- ture cardiac sphincter. It represents an overfl ow of stomach contents and is probably a result of feed- ing the neonate too fast or too much. A defect in the gastrointestinal system usually results in more severe symptoms. A small amount of regurgitation is normal, but vomiting or forceful fl uid expulsion is not. Burping the infant often during a feeding can decrease the amount of air in the stomach from swallowing. However, burping too often can lead the neonate to become tired or fussy. Moving the infant usually does not result in regurgitation. CN: Health promotion and maintenance; CL: Apply

83. After teaching the mother of a neonate with erythroblastosis fetalis who is to receive an exchange transfusion, which of the following, if stated by the mother as the purpose of the transfu- sion, indicates effective teaching? ■ 1. To replenish the neonate's leukocytes. ■ 2. To restore the fl uid and electrolyte balance. ■ 3. To correct the neonate's anemia. ■ 4. To replace Rh-negative blood with Rh-positive blood.

83. 3. An exchange transfusion is done to reduce the blood concentration of bilirubin and correct the anemia. The exchange transfusion does not replen- ish the white blood cells or restore the fl uid and electrolyte balance. The neonate's Rh-positive blood is replaced by Rh-negative blood. CN: Reduction of risk potential; CL: Apply

95. A woman who has delivered a healthy new- born is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemor- rhage and notify the healthcare provider about? ■ 1. Bleeding that becomes lighter each day ■ 2. Clots the size of golf balls ■ 3. Saturating a pad in an hour ■ 4. Lochia that last longer than 1 week

95. 3. A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fi st or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum. CN: Health promotion and maintenance; CL: Create

83. A new antenatal G 6, P 4, Ab 1 client attends her fi rst prenatal visit with her husband. The nurse is assessing this couple's psychological response to their pregnancy. Which of the following requires the most immediate follow up? ■ 1. The couple are concerned with fi nancial changes this pregnancy causes. ■ 2. The couple expresses ambivalence about the current pregnancy. ■ 3. The father of the baby states that the preg- nancy has changed the mother's focus. ■ 4. The father of the baby is irritated that the mother is not like she was before pregnancy.

83. 4. Pregnancy creates changes in the mother and father. Being considerate, accepting changes, and being supportive of the current situation are considered acceptable responses by the father, rather than feeling irritation about these changes. Expressing concern with the fi nancial changes preg- nancy and an expanded family include is normal. The fi rst trimester involves the client and family feeling ambivalent about pregnancy and moving toward acceptance of the changes associated with pregnancy. Maternal acceptance of the pregnancy and a subsequent change in her focus are normal occurrences. CN: Health promotion and maintenance; CL: Analyze

84. A primiparous client who will be bottle- feeding her neonate asks, "What is the best position for the baby after feeding?" Which of the following positions should the nurse recommend to aid diges- tion? ■ 1. Supine position. ■ 2. On the left side. ■ 3. Prone without a pillow. ■ 4. Sitting on the caregiver's lap for 20 minutes.

84. 1. To aid digestion, the neonate should be placed in a supine position or on the right side propped with a small blanket roll after a feeding. Placing the neonate on the right side promotes gastric emptying and digestion. Placing the neonate in a prone position has been associated with sudden infant death syndrome. Although the mother may desire to hold the infant in her lap after feeding, this is not necessary for the neonate's digestion. CN: Health promotion and maintenance; CL: Apply

84. The nurse explains to the mother of a neo- nate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent dam- age primarily to which of the following organs in the neonate? ■ 1. Kidneys. ■ 2. Brain. ■ 3. Lungs. ■ 4. Liver.

84. 2. The organ most susceptible to damage from uncontrolled hemolytic disease is the brain. Bilirubin levels increase as the red blood cells are destroyed. Bilirubin crosses the blood-brain barrier and damages the cells of the central nervous system. This condition, called kernicterus, is potentially fatal. Although the kidneys, lungs, and liver may be affected by increased bilirubin levels, the brain will sustain the most life-threatening injury. CN: Reduction of risk potential; CL: Apply

84. A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth (NPO) status and is receiving intravenous (IV) fl uid replacement therapy. In plan- ning this client's care, the nurse should collaborate with the health care provider (HCP) to carry out which of the following? ■ 1. Withhold oral fl uids indefi nitely until acido- sis is corrected. ■ 2. Give oral fl uids in small quantities whenever the client desires. ■ 3. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides. ■ 4. Withhold oral fl uids until total parenteral nutrition replaces lost electrolytes.

84. 3. The client usually remains NPO for 24 hours after initiation of IV fl uid replacement thera- py. If the client is not vomiting after 24 hours, HCP orders generally allow for clients to be started on clear liquids. If the client tolerates liquids, then dry toast, crackers, or cereal may be given every 2 to 3 hours. The client should be given a choice of foods. The temperature of the foods and fl uids should be appropriate (i.e., hot food served hot, cold foods served cold). Total parenteral nutrition is initiated only if other measures, such as IV fl uid replacement and pharmacologic care, fail. CN: Physiological adaptation; CL: Create

84. A multigravid client at 39 weeks' gestation diagnosed with insulin-dependent diabetes is admit- ted for induction of labor with oxytocin (Pitocin). Which of the following should the nurse include in the teaching plan as a possible disadvantage of this procedure? ■ 1. Urinary frequency. ■ 2. Maternal hypoglycemia. ■ 3. Preterm birth. ■ 4. Neonatal jaundice.

84. 4. One of the potential disadvantages of oxytocin induction is neonatal jaundice or hyper- bilirubinemia. Oxytocin decreases the elimination of bilirubin from the neonate. Other adverse effects include maternal hypertension and frontal head- ache, which disappear when the drug is discon- tinued. The drug has antidiuretic properties that can lead to maternal water intoxication. Dangerous effects of this powerful drug include uterine hyper- stimulation or tetanic contractions, which can result in abruptio placentae and uterine rupture. Urinary frequency, maternal hypoglycemia, and preterm birth are not associated with oxytocin administra- tion. Ultrasound procedures are used to estimate gestational age to prevent preterm delivery. Clients who are diabetic commonly deliver before term because the placenta begins to deteriorate, which can result in stillbirth. CN: Pharmacological and parenteral therapies; CL: Create

84. When preparing a prenatal class about endo- crine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? ■ 1. Human placental lactogen maintains the cor- pus luteum. ■ 2. Progesterone is responsible for hyperpigmen- tation and vascular skin changes. ■ 3. Estrogen relaxes smooth muscle in the respi- ratory tract. ■ 4. The thyroid enlarges with an increase in basal metabolic rate.

84. 4. Thyroid enlargement and increased basal body metabolism are common occurrences during pregnancy. Human placental lactogen enhances milk production. Estrogen is responsible for hyper- pigmentation and vascular skin changes. Proges- terone relaxes smooth muscle in the respiratory tract. CN: Health promotion and maintenance; CL: Create

85. The nurse determines that a newborn is hypoglycemic based on which of the following fi nd- ings? Select all that apply. ■ 1. Glucometer reading of 40 mg/dL. ■ 2. Family history of insulin-dependent diabetes. ■ 3. Internal fetal monitor tracing. ■ 4. Irregular respirations, tremors, and hypothermia. ■ 5. Large for gestational age.

85. 1, 4. A glucometer reading of 40 mg/dL (or less) and irregular respirations, tremors, and hypo- thermia are indicative of hypoglycemia. Internal fetal monitors detect the strength of contractions and the fetal heart rate. An infant of an insulin- dependent mother and a large-for-gestational-age infant are at greater risk of developing hypoglycemia and need to be observed carefully but these findings are not definitive for the diagnosis of hypoglycemia. CN: Physiological adaptation; CL: Analyze

85. When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? ■ 1. External genitalia. ■ 2. Myelinization of nerves. ■ 3. Brown fat stores. ■ 4. Air ducts and alveoli.

85. 1. Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of fetal development. Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approximately 21 to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks. CN: Health promotion and maintenance; CL: Apply

85. Which of the following nursing diagnoses would be the priority for a multigravid diabetic client at 38 weeks' gestation who is scheduled for labor induction with oxytocin (Pitocin)? ■ 1. Risk for defi cient fl uid volume related to oxy- tocin infusion. ■ 2. Pain related to prolonged labor and uterine ischemia. ■ 3. Fear related to possible need for cesarean delivery. ■ 4. Risk for injury, maternal or fetal, related to potential uterine hyperstimulation.

85. 4. The highest priority nursing diagnosis for the client at this time is Risk for injury, maternal or fetal related to uterine hyperstimulation. Diabetic mothers have a higher incidence of pregnancy- induced hypertension, polyhydramnios, preterm birth, and larger-than-average fetuses and com- monly have decreased placental perfusion. Infants of diabetic mothers may have polycythemia, con- genital anomalies, and respiratory distress. Because of its antidiuretic properties, oxytocin infusion poses a risk of fl uid overload, not fl uid defi cit. There is no information to support the diagnosis of Pain related to prolonged labor. For multi- gravid clients, labor is commonly shorter than for primigravidas. A labor duration longer than 12 hours would indicate a prolonged labor. There is no indication that the client will require cesarean delivery at this time. CN: Pharmacological and parenteral therapies; CL: Analyze

85. A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should pre- pare to do which of the following? ■ 1. Transfer the client to the antenatal unit. ■ 2. Keep the client NPO for 24 hours. ■ 3. Administer magnesium sulfate. ■ 4. Obtain an ultrasound.

85. 4. The nurse should prepare the client for an ultrasound to determine the cause of the symptoms. Elevated blood pressure at this point in the preg- nancy could indicate chronic hypertension as well as hydatidiform mole. The fundal height of 19 cm is higher than is typically found at 15 weeks' gestation and is indicative of a molar pregnancy (hydatidi- form mole). The dark brown vaginal bleeding in iso- lation could indicate an abortion but when placed in context of the other symptoms is likely related to a hydatidiform mole. The continuous nausea and vomiting is abnormal at this point in the pregnancy and can be a result of the high levels of progesterone from a molar pregnancy. There is no fetus involved; the blood pressure elevation and the continuous nausea and vomiting will resolve with evacuation of the mole, negating the need for magnesium sulfate therapy and placing the client on NPO status. CN: Reduction of risk potential; CL: Synthesize

9. After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following? ■ 1. Hydrocephalic infant. ■ 2. Abruptio placentae. ■ 3. Intrauterine growth retardation. ■ 4. Poor placental perfusion.

9. 1. Congenital anomalies such as hydrocepha- lus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth retardation, and poor placental perfusion are associated with preeclampsia. Abrup- tio placentae occurs because of severe vasoconstric- tion. Intrauterine growth retardation is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction. CN: Physiological adaptation; CL: Evaluate

86. A 38-year-old client at about 14 weeks' gesta- tion is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admis- sion, the nurse would assess the client for signs and symptoms of which of the following? ■ 1. Pregnancy-induced hypertension. ■ 2. Gestational diabetes. ■ 3. Hypothyroidism. ■ 4. Polycythemia.

86. 1. Hydatidiform mole is suspected when the following are present: pregnancy-induced hyperten- sion before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gesta- tional age, and increased human chorionic gonado- trophin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from car- diac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies. CN: Reduction of risk potential; CL: Analyze

86. After instructing a primiparous client who is bottle-feeding about burping, which of the follow- ing client statements indicates that the client needs further teaching? ■ 1. "I'll burp him after 15 minutes of feeding him formula." ■ 2. "After he takes one-half ounce of formula, I'll burp him." ■ 3. "I'll burp him while he is in an upright posi- tion." ■ 4. "I'll gently pat his back to get him to burp."

86. 1. The client needs further instruction when she says burping should be done after 15 minutes of formula feeding. The entire feeding should take only 15 to 20 minutes, and the neonate should be burped before that time. During initial feedings, the burp- ing should be done after each half-ounce of formula with the neonate in an upright position, patting the neonate gently on the back. CN: Health promotion and maintenance; CL: Evaluate

86. The nurse is caring for an infant of an insulin- dependent diabetic primiparous client. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglyce- mia because of which of the following? ■ 1. Increased use of glucose stores during a dif- fi cult labor and delivery process. ■ 2. Interrupted supply of maternal glucose and continued high neonatal insulin production. ■ 3. A normal response that occurs during transi- tion from intrauterine to extrauterine life. ■ 4. Increased pancreatic enzyme production caused by decreased glucose stores.

86. 2. Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most neo- nates do not develop hypoglycemia if their mothers are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life. CN: Reduction of risk potential; CL: Analyze

86. A primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? ■ 1. Monozygotic twins result from fertilization of two ova by different sperm. ■ 2. Monozygotic twins occur by chance regard- less of race or heredity. ■ 3. Dizygotic twins are usually of the same sex. ■ 4. Dizygotic twins occur more often in primi- gravid than in multigravid clients.

86. 2. Monozygotic twinning is independent of race, age, parity, or heredity. Monozygotic twins result from the fertilization of one ovum by two different sperm. Dizygotic twinning occurs with the fertiliza- tion of more than one ovum during conception. Dizy- gotic twins may be of the same sex or different sexes. Dizygotic twinning is correlated with increased parity, becoming pregnant within 1 month after stopping oral contraception, and infertility treatments. A primigrav- id client is less likely to conceive dizygotic twins. CN: Health promotion and maintenance; CL: Apply

86. A multigravid client is receiving oxytocin (Pitocin) augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontane- ously with meconium-stained amniotic fluid. Which of the following actions should the nurse do first? ■ 1. Increase the rate of the oxytocin infusion. ■ 2. Turn the client to a knee-to-chest position. ■ 3. Assess cervical dilation and effacement. ■ 4. Monitor the fetal heart rate continuously.

86. 4. A common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is meconium-stained fl uid. Because the fetus has suffered hypoxia, close fetal heart rate monitor- ing is necessary. In addition, all clients are moni- tored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (e.g., late decelera- tions), the physician should be notifi ed immedi- ately. A cesarean delivery may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the cli- ent to the left side, rather than a knee-chest position, improves placental perfusion. The physician may wish to determine the extent of cervical dilation to make a decision about whether a cesarean delivery is warranted, but continuous fetal heart rate moni- toring is essential to determine fetal status. CN: Reduction of risk potential; CL: Synthesize

87. During a 2-hour childbirth preparation class focusing on the labor and delivery process for primi- gravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is the presenting part. In which order do these maneuvers occur? 1. Engagement 2. Flexion 3. Descent 4. Internal rotation

87. 1. Engagement 3. Descent 2. Flexion 4. Internal rotation Engagement refers to the fetus' entering the true pel- vis and occurs before descent in primiparas and con- currently in multiparous women. If the head is the presenting part, the normal maneuvers during labor and delivery are (in order): descent, fl exion, internal rotation, extension, external rotation, and expulsion. These maneuvers are called the cardinal movements. They occur as the fetal head passes through the maternal pelvis during the normal labor process. CN: Health promotion and maintenance; CL: Apply

87. When caring for the neonate of a diabetic mother weighing 4,564 g (10 lb, 1 oz) who was delivered vaginally, the nurse should assess the neo- nate for fracture of the: ■ 1. Clavicle. ■ 2. Skull. ■ 3. Wrist. ■ 4. Rib cage.

87. 1. Infants born to diabetic mothers tend to be larger than average, and this neonate weighs 10 lb, 1 oz (4,564 g). The most common fractures are those of the clavicle and long bones, such as the femur. In a neonate, the skull bones are not fused and move to allow for vaginal delivery, so skull fracture is rarely seen. Wrist and rib cages are rarely fractured. CN: Reduction of risk potential; CL: Apply

87. After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important? ■ 1. Urinary tract infection. ■ 2. Hemorrhage. ■ 3. Abdominal distention. ■ 4. Chorioamnionitis.

87. 2. After D&C to evacuate a molar pregnancy, the nurse should assess the client's vital signs and monitor for signs of hemorrhage, because the surgi- cal procedure may have traumatized the uterine lin- ing, leading to hemorrhage. Urinary tract infections, not common after evacuation of a molar pregnancy, are most commonly related to urinary catheteriza- tion. Typically, urinary catheters are not used during evacuation of a molar pregnancy. The client should not experience abdominal distention, because the contents of the uterus have been removed. Chorio- amnionitis is an infl ammation of the amniotic fl uid membranes. With complete mole, no embryonic or fetal tissue or membranes are present. CN: Reduction of risk potential; CL: Analyze

87. When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently? ■ 1. 5 to 7 months. ■ 2. 8 to 10 months. ■ 3. 12 to 14 months. ■ 4. 15 to 16 months.

87. 2. Most babies are developmentally ready to drink independently from a cup by the age of 8 to 10 months. If the child has not mastered drinking from a cup by this time, there may be a problem with motor development that requires further investigation. CN: Health promotion and maintenance; CL: Apply

87. A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client's neonate? ■ 1. Hyperirritability. ■ 2. Hyperbilirubinemia. ■ 3. Low birth weight. ■ 4. Hypocalcemia.

87. 3. Neonates born to mothers who smoke tend to have lower-than-average birth weights. Neo- nates born to mothers who smoke also are at higher risk for stillbirth, sudden infant death syndrome, bronchitis, allergies, delayed growth and develop- ment, and polycythemia. Maternal smoking is not related to higher neonatal hyperirritability, hyper- bilirubinemia, or hypocalcemia. Rather, cocaine use during pregnancy is associated with neonatal hyperirritability and withdrawal symptoms. Hyper- bilirubinemia is associated with Rh or ABO incom- patibility or the administration of intravenous oxy- tocin during labor. Approximately 50% of neonates born to mothers with insulin-dependent diabetes experience hypocalcemia during the fi rst 3 days of life. CN: Health promotion and maintenance; CL: Analyze

88. While caring for a neonate of a diabetic mother soon after delivery, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate's blood glucose level and it is 60 mg/dL, but the neonate continues to exhibit jitteriness and tremors. The nurse should fi rst: ■ 1. Inform the physician of the neonate's glucose levels and tremors and request an order for blood calcium levels. ■ 2. Administer glucose intravenously based on infant glucose level. ■ 3. Take the neonate's temperature and place him in the radiant warmer. ■ 4. Refeed the infant to continue to increase the blood glucose level.

88. 1. This neonate has a diabetic mother who tends to have higher calcium levels, which can cause secondary hypoparathyroidism in their neo- nates. This lack of calcium may be the cause of the tremors and jitteriness of this neonate and a serum calcium level should be obtained. Other factors contributing to hypocalcemia in neonates include hypophosphatemia from tissue metabolism, vitamin D antagonism from increased cortisol levels and decreased serum magnesium levels. Beginning a glucose IV based on a normal infant glucose level would have no benefi t. Rechecking the neonate's temperature is a precaution that can be taken to assure that it is within normal limits but is not the action to take fi rst. Refeeding the infant who has a normal newborn blood glucose level is not appropriate. CN: Management of care; CL: Synthesize

88. When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which of the following? ■ 1. Ectopic pregnancy. ■ 2. Choriocarcinoma. ■ 3. Multifetal pregnancies. ■ 4. Infertility.

88. 2. A client who has had a hydatidiform mole removed should have regular checkups to rule out the presence of choriocarcinoma, which may complicate the client's clinical picture. The client's human chorionic gonadotropin (hCG) levels are monitored for 1 year. During this time, she should be advised not to become pregnant because this would be refl ected in rising hCG levels. Ectopic or multifetal pregnancy is not associated with hyda- tidiform mole. Women who have molar pregnancies have fertility rates similar to the general population. CN: Reduction of risk potential; CL: Synthesize

88. When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the nurse instructs the client not to "prop" the bottle while feeding the neonate because this can lead to which of the following? ■ 1. Overfeeding and obesity. ■ 2. Aspiration of the formula. ■ 3. Tooth decay in the formative months. ■ 4. Sudden infant death syndrome (SIDS).

88. 2. Bottle "propping" is not recommended because it can lead to aspiration, delayed bonding, feelings of mistrust (Erikson), and possible otitis media. The neonate will not be overfed during bottle propping but may suck too quickly, possibly result- ing in aspiration of the formula. Putting the neonate to bed with a bottle can lead to tooth decay later in the formative years, but an infant cannot hold the bottle. The cause of SIDS has not been determined. However, it is associated with placing the infant in a prone position after eating. CN: Reduction of risk potential; CL: Synthesize

88. A primigravid client who has had a pro- longed labor but now is completely dilated has received epidural anesthesia. Which of the follow- ing should the nurse include in the teaching plan about pushing? ■ 1. The client needs to push for at least 1 to 3 minutes. ■ 2. Pushing is most effective when the client holds her breath. ■ 3. The client should be urged to push with an open glottis. ■ 4. Pushing is limited to times when she feels the urge.

88. 3. The client should be urged to push with an open glottis to prevent the Valsalva maneuver. Pushing with a closed glottis increases intrathoracic pressure, preventing venous return. Blood pressure also falls, and cardiac output decreases. Pushing for at least 1 to 3 minutes is too long; prolonged pushing can lead to reduced blood fl ow and fatigue. Pushing for the duration of the contraction is suf- fi cient. Pushing while holding the breath results in the Valsalva maneuver. Because the client has had an epidural anesthetic, she may not feel the urge to push and may need coaching during the pushing phase. CN: Pharmacological and parenteral therapies; CL: Create

90. The physician orders an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure? ■ 1. To decrease the frequency and severity of variable decelerations. ■ 2. To minimize the possibility of fetal metabolic alkalosis. ■ 3. To increase the fetal heart rate accelerations during a contraction. ■ 4. To raise the amniotic fluid index to more than 15 cm.

90. 1. Oligohydramnios, or a decrease in the volume of amniotic fl uid, is associated with variable fetal heart rate decelerations due to cord compres- sion. Maintenance of an adequate amniotic fl uid volume during labor provides protective cushioning of the umbilical cord and minimizes cord compres- sion. Cord compression can result in fetal metabolic acidosis, not alkalosis. Amnioinfusion is used to minimize cord compression, not to increase the fetal heart rate accelerations during a contraction. The goal is to maintain the amniotic fl uid index at 8 cm. This can be determined by ultrasound. CN: Reduction of risk potential; CL: Apply

89. After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid cli- ent asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the fol- lowing time spans? ■ 1. 6 months. ■ 2. 12 months. ■ 3. 18 months. ■ 4. 24 months.

89. 2. A client who has experienced a molar pregnancy is at risk for development of choriocar- cinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradu- ally begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrex- ate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy. CN: Reduction of risk potential; CL: Apply

89. Which of the following statements by a primigravid client about the amniotic fl uid and sac indicates the need for further teaching? ■ 1. "The amniotic fl uid helps to dilate the cervix once labor begins." ■ 2. "Fetal nutrients are provided by the amniotic fl uid." ■ 3. "Amniotic fl uid provides a cushion against impact of the maternal abdomen." ■ 4. "The fetus is kept at a stable temperature by the amniotic fl uid and sac."

89. 2. Although the amniotic fl uid promotes normal prenatal development by allowing sym- metric development, it does not provide the fetus with nutrients. Rather, nutrients are provided by the placenta. The amniotic fl uid does help dilate the cervix once labor begins by pressure and gravity forces. The amniotic fl uid helps to protect the fetus from injury by cushioning against impact of the maternal abdomen and allows room and buoyancy for fetal movement. The amniotic fl uid and sac keep the fetus at a stable temperature by maintaining a neutral thermal environment. CN: Health promotion and maintenance; CL: Evaluate

89. The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explana- tion for using forceps based on the understanding about which of the following concerning the loca- tion of the fetal skull? ■ 1. It is engaged past the inlet. ■ 2. It is at +1 station. ■ 3. It is visible at the perineal fl oor. ■ 4. It has reached the level of the ischial spines.

89. 3. The American College of Obstetricians and Gynecologists has classifi ed forceps applica- tions into three categories: outlet, low, or middle. When the fetal skull is on the perineum with the scalp visible at the perineal fl oor or vaginal opening, this is considered outlet forceps application. When the head is higher in the pelvis but engaged and its greatest diameter has passed the inlet, the operation is termed midforceps. Midforceps deliveries are not recommended because they are extremely danger- ous for the mother and fetus because of the possibil- ity of uterine rupture. If the head is not engaged, at -1 station, this is termed high forceps. High forceps deliveries also are exceedingly dangerous for both the mother and fetus because of the possibility of uterine rupture and are not recommended. Cesarean delivery is preferred in these situations. The fetal head at station +2 or lower is termed low forceps. CN: Reduction of risk potential; CL: Apply

9. A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care? ■ 1. Urine toxicology screening. ■ 2. Notifying hospital security. ■ 3. Limiting contact with visitors. ■ 4. Contacting local law enforcement.

9. 1. A urine toxicology screening will be col- lected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant. If the infant tests positive for cocaine, the legal sys- tem will be activated to provide and ensure protec- tive custody for this child. Hospital security would not become involved unless the mother is obtaining or using drugs on hospital premises. The mother and infant have the same privileges as any hospital- ized clients unless the safety of the infant is jeop- ardized, thus limiting contact with visitors would not be appropriate. Local law enforcement agencies would be contacted only if the mother initiates use of the drugs on hospital premises and such con- tact would be made through the hospital security system. CN: Physiological adaptation; CL: Synthesize

The Postpartal Client with a Cesarean Birth 89. The nurse is assessing a cesarean section client who delivered 12 hours ago. Findings include a distended abdomen with faint bowel sounds × 1 quadrant, fundus fi rm at umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The I.V. and Foley catheter have been discontinued and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. The nurse should fi rst: ■ 1. Give the client pain medication. ■ 2. Have the client use the incentive spirometry. ■ 3. Ambulate the client from the bed to the hall- way and back. ■ 4. Encourage the client to begin caring for her baby.

89. 3. The client should have more active bowel sounds by this time postpartum. Ambulation will encourage passing fl atus and begin peristaltic action in the gastrointestinal track. Medicating the cli- ent should be evaluated prior to ambulating but it is probably too soon because the last dose was 3 hours ago and her pain assessment rating is fairly low. Pain medications should not have codeine as a component as it decreases peristaltic activity. Incen- tive spirometry or asking the client to turn, cough and deep breathe are appropriate to encourage good oxygen exchange in the lungs prior to ambulation, and walking can be used concurrently with these intervention. Participating in infant care is another way to encourage the mother to move about but the primary goal would be to have her walk on the unit, a more purposeful activity. CN: Physiological adaptation; CL: Synthesize

89. The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean delivery 1 hour ago. The mother is a class B insulin- dependent diabetic primipara. She asks the nurse, "Why is my baby in the neonatal intensive care unit?" The nurse bases a response on the understanding that neonates of class B diabetic mothers commonly develop which of the following conditions? ■ 1. Anemia. ■ 2. Persistent pulmonary hypertension. ■ 3. Hemolytic disease. ■ 4. Hypoglycemia.

89. 4. Hypoglycemia is caused by the rapid depletion of glucose stores. In addition, neonates born to class B diabetic women are about seven times more likely to suffer from respiratory dis- tress syndrome than neonates born to nondiabetic women. This neonate should be closely monitored for symptoms of hypoglycemia and respiratory distress. Neonates of diabetic mothers commonly have polycythemia, not anemia. Anemia and hemo- lytic disease are associated with erythroblastosis fetalis. Persistent pulmonary hypertension is associ- ated with meconium aspiration syndrome. CN: Reduction of risk potential; CL: Apply

9. A primigravid client is admitted as an out- patient for an external cephalic version. The nurse should assess the client for which of the following contraindications for the procedure? ■ 1. Multiple gestation. ■ 2. Breech presentation. ■ 3. Maternal Rh-negative blood type. ■ 4. History of gestational diabetes.

9. 1. External cephalic version is the turning of the fetus from a breech position to the vertex position to prevent the need for a cesarean deliv- ery. Gentle pressure is used to rotate the fetus in a forward direction to a cephalic lie. Contraindica- tions to the procedure include multiple gestation because of the potential for fetal injury or uterine injury, severe oligohydramnios (decreased amni- otic fl uid), contraindications to a vaginal birth (e.g., cephalopelvic disproportion), and unexplained third trimester bleeding. If the mother has Rh- negative blood type, the procedure can be performed and Rh immunoglobulin should be administered in case minimal bleeding occurs. A history of gesta- tional diabetes is not a contraindication unless the fetus is large for gestational age and the client has cephalopelvic disproportion. CN: Reduction of risk potential; CL: Analyze

9. A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by con- vection, the nurse should: ■ 1. Move the infant away from cool window sur- faces. ■ 2. Make certain the infant has no contact with cool surfaces. ■ 3. Dry the infant's skin with a towel. ■ 4. Position the infant away from drafts and cool- ing ducts. Use rationale in 9th Edition, page 132. (A)

9. 2. Keeping the neonate away from drafts and cooling ducts prevents heat loss by convection (fl ow of heat from the body surface to the cooler sur- rounding air). The neonate also loses heat through evaporation (conversion of a liquid to a vapor, as when a wet surface, such as the neonate's skin, is exposed to air); conduction (transfer of body heat to a cooler solid object in contact with the baby, as when the neonate comes in direct contact with a cold surface such as a scale or a cold stethoscope); and radiation (transfer of heat to cooler solid objects that are not in direct contact with the baby, as when the neonate is placed near a cold window surface or air conditioner). CN: Health promotion and maintenance; CL: Apply

9. After instructing a 20-year-old nulligravid cli- ent about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which of the following as an adverse effect? ■ 1. Weight gain. ■ 2. Nausea. ■ 3. Headache. ■ 4. Ovarian cancer.

9. 4. The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovar- ian and endometrial cancer are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is throm- bophlebitis.

90. Carboprost (Hemabate) was injected into the uterus of a client to treat uterine atony during a cesarean section. In preparing to care for this client postpartum, the nurse should assess the client for which of the following common adverse effects of the medication? ■ 1. Vertigo and confusion. ■ 2. Nausea and diarrhea. ■ 3. Restlessness and increased vaginal bleeding. ■ 4. Headache and hypertension.

90. 2. Hemabate is an oxytocic prostaglandin that causes uterine contraction in women who are bleeding heavily. Nausea, vomiting, diarrhea, and fever are common adverse effects of prostaglan- din administration. Vertigo and confusion are not associated with this drug. Vaginal bleeding may occur with inadequate amounts of Hemabate if the client continues to bleed. Restlessness may result if inadequate amounts of Hemabate are used and the woman continues to bleed and goes into shock. If too large a dose is given, the client may experience headache and hypertension because Hemabate does contract smooth muscles.

90. While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a prim- iparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal? ■ 1. Bradycardia. ■ 2. High-pitched cry. ■ 3. Sluggishness. ■ 4. Hypocalcemia.

90. 2. Manifestations of cocaine withdrawal in the neonate include a shrill, high-pitched cry; tachycardia; muscle rigidity; irritability; restless- ness; fi st-sucking; and an exaggerated startle refl ex. These signs usually appear within 72 hours and persist for several days. These neonates are diffi cult to console, have poor feeding behaviors, and have diarrhea. Bradycardia is associated with preterm neonates. Sluggishness and lethargy are associated with neonates whose mothers received analgesia shortly before delivery. Hypocalcemia occurs most commonly in infants of diabetic mothers, premature infants, and low-birth-weight infants. CN: Reduction of risk potential; CL: Analyze

90. The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? ■ 1. Client at 40 weeks' gestation whose fetus weighs 8 lb by ultrasound estimate. ■ 2. Client at 37 weeks' gestation with fetus in ROP position. ■ 3. Client at 32 weeks' gestation with fetus in breech position. ■ 4. Client at 38 weeks' gestation with active her- pes lesions.

90. 4. Herpes simplex virus can be transmitted to the infant during a vaginal delivery. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb will be given a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will have a slow labor with increased back pain but can deliver vagi- nally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months' gestation, the breech position is not a concern. CN: Physiological adaptation; CL: Evaluate

91. The nurse notices that a client who has just delivered her infant is short of breath, ashen in color, and begins to cough. She becomes limp on the delivery table. At last assessment 1⁄2 hour ago, her tempature was 98, pulse 78, respirations 16. Deter- mine the nursing actions in the order they should occur. 1. Open airway using head tilt-chin lift. 2. Ask staff to activate emergency response system. 3. Establish unresponsiveness. 4. Give 2 breaths. 5. Check the pulse

91. 3. Establish unresponsiveness. 2. Ask staff to activate emergency response system. 1. Open airway using head tilt-chin lift. 4. Give 2 breaths. 5. Check the pulse The client's actions indicate distress and the nurse should initiate emergency procedures. The nurse should fi rst establish unresponsiveness and then ask staff to activate the emergency response system. Next, the nurse should assure an open airway and then give 2 breaths. The nurse should then check the carotid pulse, and if necessary begin chest com- pressions. CN: management of care; CL: Synthesize

91. A client is experiencing pain during the fi rst stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. ■ 1. Walk in the hospital room. ■ 2. Use slow chest breathing. ■ 3. Request pain medication on a regular basis. ■ 4. Lightly massage her abdomen. ■ 5. Sip ice water.

91. 1, 2, 4. Pain during the fi rst stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching of the lower uterine segment, dilatation of the cervix and perineum, and pressure on adjacent structures. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles. Slow chest breathing is appropriate during the fi rst stage of labor to promote increased oxygenation as well as relaxation. The woman or her coach can lightly massage the abdomen (effl eurage) while using slow chest breathing. Chest breathing and massag- ing increase oxygenation and relaxation of uterine muscles. Pain medication is not used during the fi rst stage of labor because most medications will slow labor; anesthesia may be considered during the second stage of labor. Sipping ice water, while help- ful for maintaining hydration, will not be useful as a pain management strategy. CN: Health promotion and maintenance; CL: Synthesize

91. After teaching a primiparous client who used cocaine during pregnancy about possible gastroin- testinal signs and symptoms in her neonate, which of the following, if stated by the mother as common, indicates effective teaching? ■ 1. Hypotonia. ■ 2. Constipation. ■ 3. Vomiting. ■ 4. Abdominal distention.

91. 3. Neonates experiencing cocaine withdrawal have gastrointestinal problems similar to those of adults withdrawing from cocaine. The neonates exhibit poor sucking, vomiting, drooling, diarrhea, regurgitation, and anorexia. In addition, they are diffi cult to console and diffi cult to feed. Because of these problems, the neonate withdrawing from cocaine needs to be monitored carefully to prevent dehydration. Neonates with cocaine exposure expe- rience hypertonia, not hypotonia, due to increased central nervous system irritability. Diarrhea, not constipation, is seen in these neonates. Abdominal distention is associated with necrotizing enterocoli- tis, not cocaine withdrawal. CN: Reduction of risk potential; CL: Evaluate

91. The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with pregnancy-induced hypertension to the labor and delivery area. Which of the following client care rooms is most appropriate for this client? ■ 1. A brightly lit private room at the end of the hall from the nurses' station. ■ 2. A semiprivate room midway down the hall from the nurses' station. ■ 3. A private room with many windows that is near the operating room. ■ 4. A darkened private room as close to the nurses' station as possible.

91. 4. A primigravid client diagnosed with preg- nancy-induced hypertension has the potential for developing seizures (eclampsia). This client should be in a room with the least amount of stimulation possible to reduce the risk of seizures and as close to the nurses' station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risk of seizures, as can being in a semiprivate room with roommate, visitors, conversation, and noise. CN: Management of care; CL: Synthesize

91. A 30-year-old woman, G 4, P 4, has delivered a healthy term female neonate by cesarean delivery due to a nonreassuring fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's retention catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next? ■ 1. Continue to monitor the client's input and output. ■ 2. Palpate the client's fundus gently every 15 minutes. ■ 3. Assess the placement of the retention cath- eter. ■ 4. Contact the client's physician for further orders.

91. 4. Slightly red-tinged urine may indicate that the bladder was accidentally cut during the cesarean delivery. The nurse should notify the physician as soon as possible about the urine color. Continuing to monitor the client's input and output should be done after the physician is contacted. Palpating the fundus every 15 minutes is not necessary unless the client's fundus becomes soft or "boggy." Assess- ment of the retention catheter is a normal part of the elimination assessment by the nurse, but displace- ment is not the cause of the red-tinged urine. CN: Reduction of risk potential; CL: Synthesize

92. When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to: ■ 1. Tightly swaddle the neonate. ■ 2. Feed the neonate extra, high-calorie formula. ■ 3. Keep the neonate in a brightly lit environ- ment. ■ 4. Touch the baby only when he is crying.

92. 1. A neonate undergoing cocaine withdrawal is irritable, often restless, diffi cult to console, and often in need of increased activity. It is com- monly helpful to swaddle the neonate tightly with a blanket, offer a pacifi er, and cuddle and rock the neonate. Offering extra nourishment is not advised because overfeeding tends to increase gastroin- testinal problems such as vomiting, regurgitation, and diarrhea. Environmental stimuli such as bright lights and loud noises should be kept to a minimum to decrease agitation. Minimizing touching of the neonate to only when he or she is crying will not aid the bonding process between mother and neonate. Frequent holding and touching are permissible. CN: Reduction of risk potential; CL: Synthesize

92. While changing the neonate's diaper, the cli- ent asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate? ■ 1. "It's of no concern because it is such a small amount." ■ 2. "The cause is usually related to swallowing blood during the delivery." ■ 3. "Sometimes baby girls have this from hor- mones received from the mother." ■ 4. "This vaginal spotting is caused by hemor- rhagic disease of the newborn."

92. 3. The most appropriate response would be to explain that the vaginal spotting in female neo- nates is associated with hormones received from the mother. Estrogen is believed to cause slight vaginal bleeding or spotting in the female neonate. The con- dition disappears spontaneously, so there is no need for concern. Telling the mother that it is of no con- cern does not allay the mother's worry. The vaginal spotting is related to hormones received from the mother, not to swallowing blood during the delivery or hemorrhagic disease of the neonate. Anemia is associated with hemorrhagic disease. CN: Health promotion and maintenance; CL: Synthesize

92. A client in sickle cell crisis has been hos- pitalized during her pregnancy. After giving dis- charge instructions, the nurse determines the client needs further teaching when she states which of the following? ■ 1. "I will need more frequent appointments dur- ing the remainder of the pregnancy." ■ 2. "Signs of any type of infection must be reported immediately." ■ 3. "At the earliest signs of a crisis, I need to seek treatment." ■ 4. "I have this disease because I don't eat enough food with iron."

92. 4. Sickle cell disease is an autosomal reces- sive disorder requiring both parents to have a sickle cell trait to pass the disease to a child. Deoxygenated hemoglobin cells assume a sickle shape and ob- struct tissues. Tissue obstruction causes hypoxia to the area (vasoocclusion) and results in pain, called sickle cell crisis. This type of anemia is an inherited disorder; it is not caused by lack of iron in the diet. Self-monitoring for any type of infections or sickle cell crisis and increased frequency of antenatal care visits are part of the teaching plan of care. CN: Physiological adaptation; CL: Evaluate

92. A multigravid client is admitted to the labor area from the emergency room. At the time of admis- sion, the fetal head is crowning, and the client yells, "The baby's coming!" To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate? ■ 1. "You're right, the baby is coming, so just relax." ■ 2. "Please don't push because you'll tear your cervix." ■ 3. "Your doctor will be here as soon as pos- sible." ■ 4. "I'll explain what's happening to guide you as we go along."

92. 4. The client is experiencing a precipitous delivery. The nurse should remain calm during a precipitous delivery. Explaining to the client what is happening as the birth progresses and how she can assist is likely to help her remain calm and coopera- tive. Maintaining eye contact is also benefi cial. Telling the client that she is right and to just relax is inap- propriate because the client may not be able to relax because of the strong urge to push the fetus out of the birth canal. Telling the client not to push because she may tear the cervix can instill fear, not cooperation. Saying that the physician will be there soon may not be an accurate statement and is not reassuring if the client is concerned about the delivery. CN: Psychosocial adaptation; CL: Apply

92. During a Preparation for Parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" The nurse should tell the participant which of the following about true labor contractions? ■ 1. "Walking around helps to decrease true con- tractions." ■ 2. "True labor contractions may disappear with ambulation, rest, or sleep." ■ 3. "The duration and frequency of true labor contractions remain the same." ■ 4. "True labor contractions are felt fi rst in the lower back, then the abdomen."

92. 4. With true labor, the contractions are felt fi rst in the lower back and then the abdomen. They gradually increase in frequency and duration and do not disappear with ambulation, rest, or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase true contractions. False labor contrac- tions disappear with ambulation, rest, or sleep. False labor contractions commonly remain the same in duration and frequency. Clients who are experi- encing false labor may have pain, even though the contractions are not very effective. CN: Health promotion and maintenance; CL: Apply

93. A laboring client at -2 station has a sponta- neous rupture of the membranes and a cord imme- diately protrudes from the vagina. The nurse should fi rst: ■ 1. Place gentle pressure upward on the fetal head. ■ 2. Place the cord back into the vagina to keep it moist. ■ 3. Begin oxygen by face mask at 8 to 10 L/min. ■ 4. Turn the client on her left side.

93. 1. The nurse should place a hand on the fetal head and provide gentle upward pressure to re- lieve the compression on the cord. Doing so allows oxygen to continue fl owing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother but, until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes to increase perfusion to the infant by relieving cord compression. CN: management of care; CL: Synthesize

93. Four hours after cesarean delivery of a neo- nate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean delivery (VBAC) on which of the following? ■ 1. VBAC may be possible if the client has not had a classic uterine incision. ■ 2. A history of rapid labor is a necessary crite- rion for VBAC. ■ 3. A low transverse incision contraindicates the possibility for VBAC. ■ 4. VBAC is not possible because the neonate was large for gestational age.

93. 1. VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A physician must be available, and a cesarean delivery must be possi- ble within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than 4,000 g by itself is not a contraindication if the mother is not diabetic. CN: Health promotion and maintenance; CL: Apply

93. The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After call- ing for assistance and helping the client lie down, which of the following actions should the nurse do next? ■ 1. Tell the client to push between contractions. ■ 2. Provide gentle support to the fetal head. ■ 3. Apply gentle upward traction on the neo- nate's anterior shoulder. ■ 4. Massage the perineum to stretch the perineal tissues.

93. 2. During a precipitous delivery, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent it from coming out. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Prior- ity should be given to safe delivery of the infant over protecting the perineum by massage. CN: Reduction of risk potential; CL: Synthesize

93. A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodefi ciency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following? ■ 1. "More than 50% of neonates born to mothers who are positive for HIV will be positive at 18 months of age." ■ 2. "An enlarged liver at birth generally means the neonate is HIV positive." ■ 3. "A complete blood count analysis is the primary method for determining whether the neonate is HIV positive." ■ 4. "Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time."

93. 4. Although most neonates are asymptomatic, they do test positive for HIV at birth because of the mother's antibodies. It may take several months before an accurate diagnosis can be made. It is estimated that 20% to 40% of all HIV-positive mothers deliver HIV- positive infants. With appropriate drug intervention to the mother during pregnancy, 95% of these neonates can be born unaffected. An enlarged liver at birth is associated with erythroblastosis fetalis, not HIV infec- tion. Virologic testing, such as deoxyribonucleic acid polymerase chain reaction, viral culture, or ribonu- cleic acid plasma assay, can diagnose HIV infection by 6 months of age and commonly in the fi rst month. CN: Reduction of risk potential; CL: Apply

93. After instructing participants in a childbirth education class about methods for coping with dis- comforts in the fi rst stage of labor, the nurse deter- mines that one of the pregnant clients needs further instruction when she says that she has been practic- ing which of the following? ■ 1. Biofeedback. ■ 2. Effleurage. ■ 3. Guided imagery. ■ 4. Pelvic tilt exercises.

93. 4. Pelvic tilt exercises are useful to alleviate backache during pregnancy and labor but are not useful for the pain from contractions. Biofeedback (a conscious effort to control the response to pain), ef- fl eurage (light uterine massage), and guided imagery (focusing on a pleasant scene) are appropriate pain relief techniques to practice before labor begins. Various breathing exercises also can help to alleviate the discomfort from contraction pain. CN: Health promotion and maintenance; CL: Evaluate

94. A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? Select all that apply. ■ 1. −2 station. ■ 2. Low birth weight infant. ■ 3. Rupture of membranes. ■ 4. Breech presentation. ■ 5. Prior abortion. ■ 6. Low lying placenta.

94. 1, 2, 3, 4. Having the fetus at a negative sta- tion places the client at risk for a cord prolapse. With a negative station, there is room between the fetal head and the maternal pelvis for the cord to slip through. A small infant is more mobile within the uterus and the cord can rest between the fetus and the inside of the uterus or below the fetal head. With a large infant, the head is usually in a vertex presentation and occludes the lower portion of the uterus, preventing the cord from slipping by. When membranes rupture, the cord can be swept through with the amniotic fl uid. In a breech presentation, the fetal head is in the fundus and smaller portions of the fetus settle into the lower portion of the uterus, allowing the cord to lie beside the fetus. Prior abor- tion and a low lying placenta have no correlation to cord prolapse. CN: Physiological adaptation; CL: Analyze

94. During the first hour after a precipitous deliv- ery, the nurse should monitor a multiparous client for signs and symptoms of which of the following? ■ 1. Postpartum "blues." ■ 2. Uterine atony. ■ 3. Intrauterine infection. ■ 4. Urinary tract infection.

94. 2. Because delivery occurs so rapidly and the fetus is propelled quickly through the birth canal, the major complication of a precipitous delivery is a boggy fundus, or uterine atony. The neonate should be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the physician will probably order administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm. There is no relationship between a precipi- tous delivery and postpartum "blues" or intrauterine infection. Postpartum "blues" usually does not occur until about 3 days postpartum, and symptoms of post- partum infection usually occur after the first 24 hours. There is no relationship between a precipitous delivery and urinary tract infection even though the delivery has been accomplished under clean rather than sterile technique. Symptoms of urinary tract infection typi- cally begin on the first or second postpartum day. CN: Reduction of risk potential; CL: Analyze

94. After a Preparation for Parenting class ses- sion, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse's best action is to advise the client to do which of the following? ■ 1. Use an over-the-counter cream for yeast i nfections. ■ 2. Schedule an appointment at the clinic for an examination. ■ 3. Administer a vinegar douche under low pressure. ■ 4. Prepare for preterm labor and delivery.

94. 2. Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge with local itching is associated with infection (e.g., Trichomonas vaginalis). The client's symptoms must be further assessed by a health professional because the client needs treatment for this condi- tion. T. vaginalis infection is commonly treated with metronidazole (Flagyl). However, this drug is not used in the fi rst trimester. In the fi rst trimester, the typical treatment is topical clotrimazole. Although a yeast infection is associated with vaginal itching, the vaginal discharge is cheese-like. Furthermore, because the client may have a serious vaginal infec- tion, over-the-counter medications are not advised until the client has been evaluated. Douching is not recommended during pregnancy because it would predispose the client to an ascending infection. The client is not exhibiting signs and symptoms of preterm labor, such as contractions or leaking fl uid. And although the client's complaints are suggestive of a T. vaginalis infection, which can lead to preterm labor and premature rupture of the membranes, fur- ther evaluation is needed to confi rm the cause of the infection. CN: Health promotion and maintenance; CL: Synthesize

94. A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should: ■ 1. Offer the client a carbonated beverage twice daily. ■ 2. Tell the client to use a straw when drinking fl uids. ■ 3. Limit the client to a soft diet until more bowel sounds exist. ■ 4. Encourage ambulation in the hallway.

94. 4. Abdominal distention, a major source of discomfort for the postoperative client, is best relieved by having the client ambulate more fre- quently. Ambulation stimulates circulation and peristalsis, thereby promoting the passage of fl atus. Carbonated beverages contribute to additional gas formation, as can drinking through a straw, and should be avoided. The client can progress from full liquids to soft foods and then to a regular diet, once bowel sounds are present. The client does not need to limit her diet to soft foods, but she may wish to avoid foods that increase intestinal gas, such as beans or brussel sprouts. CN: Basic care and comfort; CL: Synthesize

94. When caring for a multiparous client who is human immunodefi ciency virus (HIV)-positive and asking to breast-feed her neonate as soon as possi- ble, which of the following instructions about breast milk should the nurse include in the teaching plan? ■ 1. It may help prevent the spread of the HIV virus. ■ 2. It contains antibodies that can protect the neonate from HIV. ■ 3. It can be benefi cial for the bonding process. ■ 4. It has been found to contain the retrovirus HIV.

94. 4. Breast milk has been found to contain the retrovirus HIV. In general, mothers are discouraged from breast-feeding if they are HIV positive because of the risk of possible transmission of the virus if the neonate is HIV negative. Breast milk does contain some immunoglobulins, but it does not protect the neonate from HIV infection. CN: Health promotion and maintenance; CL: Create

95. The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their fi rst half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan? ■ 1. Decreased plasma volume. ■ 2. Increased risk for urinary tract infections. ■ 3. Increased peripheral vascular resistance. ■ 4. Increased hemoglobin levels.

95. 2. During pregnancy, urinary tract infections are more common because of urinary stasis. Clients need instructions about increasing fl uid volume intake. Plasma volume increases during pregnancy. The increase in plasma volume is more pronounced and occurs earlier than the increase in red blood cell mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable blood pres- sure. Hemoglobin levels decrease during pregnancy even though there is an increase in blood volume. CN: Health promotion and maintenance; CL: Apply

95. A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely? ■ 1. Early deceleration pattern. ■ 2. Sinusoidal pattern. ■ 3. Variable deceleration pattern. ■ 4. Late deceleration pattern.

95. 2. The fetal heart rate of a multipara diagnosed with Rh sensitization and probable fetal hydrops and anemia will most likely demonstrate a sinusoi- dal pattern that resembles a sine wave. It has been hypothesized that this pattern refl ects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. This client will most likely require a cesarean delivery to improve the fetal outcome. Early decelerations are associated with head compression; variable decelerations are associ- ated with cord compression; and late decelerations are associated with poor placental perfusion. CN: Reduction of risk potential; CL: Analyze

95. While caring for the neonate of a human immunodefi ciency virus-positive mother, the nurse prepares to administer an ordered hepatitis B intra- muscular injection at 4 hours after birth. Which of the following actions should the nurse do fi rst? ■ 1. Bathe the neonate with an antibacterial soap. ■ 2. Place the neonate under a radiant warmer. ■ 3. Wash the injection site with povidone-iodine (Betadine) solution. ■ 4. Apply clean gloves before administering the medication.

95. 4. As part of standard precautions, the nurse should don a pair of clean gloves. Additionally, the site is cleaned thoroughly with an alcohol swab before the skin is injected. Sterile gloves are not necessary. Bathing the neonate is not necessary before giving the injection. Some research suggests that bathing removes the neonate's protective skin oils. Placing the neonate under the radiant warmer is not necessary unless the neonate's temperature is subnormal. The neonate's temperature has usually stabilized by 4 hours of age. Washing the injection site with povidone-iodine before giving the injec- tion is not necessary because of the risk for possible allergy to iodine preparations. CN: Safety and infection control; CL: Synthesize

96. While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assis- tance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest? ■ 1. Football hold. ■ 2. Scissors hold. ■ 3. Cross-cradle hold. ■ 4. Cradle hold.

96. 1. After a cesarean delivery, most mothers have the greatest comfort when the neonate is positioned in the football hold with the mother in a semi-Fowler position, supporting the neonate's head in her hand and resting the neonate's body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the neo- nate easy access to the mother's breast. The scissors hold, where the mother places her hand well back on the breast to prevent touching the areola and interfering with the neonate's mouth placement, is used by the mother to hold the breast and sup- port it during breast-feeding. The cross-cradle hold is done when the mother holds the neonate's head in the hand opposite from the breast on which the neonate will feed and the mother's arm supports the neonate's body across her lap. This position can be uncomfortable because of the pressure placed on the client's incision line. For the cradle hold, the mother cradles the infant alongside the arm at the breast on which the neonate will feed. This position also can be uncomfortable because of the pressure placed on the incision line. CN: Basic care and comfort; CL: Synthesize

96. The nurse is obtaining information to support the need for improved prenatal care services in the community. Which of the following information is most important to include? ■ 1. The maternal mortality rate. ■ 2. The infant mortality rate. ■ 3. The perinatal mortality rate. ■ 4. The neonatal mortality rate.

96. 1. The maternal mortality rate is defi ned as the number of maternal deaths related to childbear- ing divided by the number of live births. Maternal mortality in the United States has been increasing in part due to inadequate prenatal care and the increas- ing number of cesarean sections. Infant mortality rate is defi ned as the number of deaths of infants younger than 12 months of age per 1,000 live births. The perinatal mortality rate includes all stillborn in- fants with a gestational age of 28 weeks or more plus all neonatal deaths before 7 days of age per 1,000 of this population. The neonatal mortality rate is the number of deaths of infants younger than 28 days of age per 1,000 live births. CN: Health promotion and maintenance; CL: Analysis

96. A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will recieve RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states: ■ 1. "RhoGAM will protect my next baby if it is Rh-negative." ■ 2. "RhoGAM will prevent antibody formation in my blood." ■ 3. "RhoGAM will be given to prevent German measles." ■ 4. "RhoGAM will be used to prevent bleeding in my newborn."

96. 2. RhoGAM is given to new mothers who are Rh-negative and not previously sensitized and who have delivered an Rh-positive infant. RhoGAM must be given within 72 hours of the delivery of the in- fant because antibody formation begins at that time. The vaccine is used only when the mother delivered an Rh-positive infant—not an Rh-negative infant. RhoGAM does not prevent German measles and is not given to a newborn. CN: Pharmacological and parenteral therapies; CL: Evaluate

96. The physician orders oxytocin to be added to the intravenous fl uids of a 30-year-old multigravid client at 37 weeks' gestation with twins after vaginal delivery. The nurse should administer the oxytocin after delivery of which of the following? ■ 1. First placenta. ■ 2. First twin. ■ 3. Second placenta. ■ 4. Second twin.

96. 3. Oxytocin, given postpartum to contract the uterus, should be administered after both twins and both placentas have been delivered. If oxytocin is given any earlier—after the fi rst twin, after the fi rst placenta, or after the second twin—the uterus will contract and make delivery of the placenta or placentas diffi cult. CN: Pharmacological and parenteral therapies; CL: Synthesize

96. A male neonate born at 38 weeks' gestation by cesarean delivery after prolonged rupture of the membranes and a maternal oral temperature of 102° F (38.8° C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the physician? ■ 1. Leukocytosis. ■ 2. Apical heart rate of 132 bpm. ■ 3. Behavioral changes. ■ 4. Warm, moist skin.

96. 3. Symptoms of infection in a neonate include subtle behavioral changes, such as lethargy and irritability, and color changes such as pallor or cyanosis. Other symptoms include temperature instability, poor feeding, gastrointestinal disorders, hyperbilirubinemia, and apnea. Leukocytosis, an elevated white blood cell count possibly as high as 30,000 cells/mm3 or more, may be normal during the fi rst 24 hours. An apical heart rate of 132 bpm is normal. Warm, moist skin is not a typical sign of infection in neonates. Typically, temperature insta- bility is common. The neonate's temperature is low and the skin is cool and dry. CN: Health promotion and maintenance; CL: Analyze

97. The nurse in the labor and delivery area receives a telephone call from the emergency room announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby's coming ... Help!" The fetal skull is crowning. The nurse should obtain which of the following infor- mation fi rst? ■ 1. Estimated date of delivery. ■ 2. Amniotic fl uid status. ■ 3. Gravida and parity. ■ 4. Prenatal history.

97. 1. A priority assessment for the nurse to make is to determine the estimated date of delivery or prob- able gestational age of the fetus. If the gestation is less than 37 weeks, the neonatal team should be called to begin resuscitative efforts if needed. Amniotic fl uid status is not important at this point, because if the fetal skull is crowning, delivery is imminent. Deter- mination of gravida and parity is part of the normal nursing history, but the priority is the status of the fetus and safe delivery. Prenatal history is part of the nursing assessment, but this information is not espe- cially relevant until the fetus is safely delivered and has been given immediate care. CN: Health promotion and maintenance; CL: Analyze

97. A client at 4 weeks postpartum tells the nurse that she can't cope any longer and is over- whelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for? ■ 1. Postpartum blues. ■ 2. Postpartum depression. ■ 3. Poor bonding. ■ 4. Infant abuse.

97. 2. The client is experiencing and verbalizing signs of postpartum depression, which usually ap- pears at about 4 weeks postpartum but can occur at any time within the fi rst year after birth. It is more severe and lasts longer than postpartum blues, also called "baby blues." Baby blues are the mildest form of depression and are seen in the later part of the fi rst week after birth. Symptoms usually disappear shortly. Depression may last several years and is disabling to the woman. Poor bonding may be seen at any time but commonly becomes evident as the mother begins interacting with the infant shortly after birth. Infant abuse may take the form of neglect or injuries to the infant. A depressed mother is at risk for injuring or abusing her infant. CN: Reduction of risk potential; CL: Synthesize

The Postpartal Client with Complications 97. While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. What action should the nurse take based on this assessment? ■ 1. Notify the health care provider of the separa- tion. ■ 2. Discuss with the client that no further action is needed. ■ 3. Demonstrate exercises involving head and shoulder lifting. ■ 4. Refer the client to a surgeon for surgical repair after 6 weeks postpartum.

97. 2. The separation of the abdominal muscles is a frequent occurrence during pregnancy and postpartum, caused by the size of the fetus and influenced by maternal hormones. The nurse should discuss the separation with the client and assure her that there are no further actions indi- cated. Exercises involving the head and shoul- ders may be initiated after the 6-week checkup to improve the muscle tone of the abdomen but exercise will not repair the separation. A referral to a surgeon for surgical repair is a personal choice of the client but would not be medically indicated for the separation. CN: Physiological adaptation; CL: Synthesize

97. The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following will the nurse need to instruct the parents to do because of the neonate's infection? ■ 1. Use caution near the isolation incubator and equipment. ■ 2. Visit but do not touch the neonate. ■ 3. Wash their hands thoroughly before touching the neonate. ■ 4. Wear a mask when holding the neonate.

97. 3. The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. The par- ents must be careful around medical equipment to ensure proper function and around the intravenous site so that it is not dislodged, but being careful with the equipment is not suffi cient to prevent transmis- sion of microbes to the neonate. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate's psychological development. Normally, the neonate does not need to be isolated. It is not necessary for the parents to wear a mask while hold- ing the neonate. The neonate is not contagious and is receiving treatment for the infection. CN: Safety and infection control; CL: Apply

97. A multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following? ■ 1. Placental blood. ■ 2. Amniotic fl uid. ■ 3. Fetal blood. ■ 4. Maternal blood.

97. 4. For the Rh-negative client who may be pregnant with an Rh-positive fetus, an indirect Coombs test measures antibodies in the maternal blood. Titers should be performed monthly during the fi rst and second trimesters and biweekly during the third trimester and the week before the due date. CN: Health promotion and maintenance; CL: Apply

98. The nurse and a nursing assistant are caring for clients in a birthing center. Which of the follow- ing tasks should the nurse delegate to the nursing assistant? Select all that apply. ■ 1. Removing a Foley catheter from a preeclamp- tic client. ■ 2. Assisting an active labor client with breathing and relaxation. ■ 3. Ambulating a postcesarean client to the bathroom. ■ 4. Calculating hourly I.V. totals for a preterm labor client. ■ 5. Intake and output catheterization for culture and sensitivity. ■ 6. Calling a report of normal fi ndings to the health care provider. ■ 7. Removing lunch trays and documenting lunch intake.

98. 2, 3, 7. The nursing assistant could assist the client with breathing and relaxation, and ambulate the postcesarean client to the bathroom. Remov- ing lunch trays and adding the intake to the input and output sheet is a nursing assistant responsibil- ity. Removing a Foley catheter would also involve assessment of bladder status and totaling the intake and output and would be a nursing responsibil- ity. Calculating the hourly I.V. totals for a preterm labor client would involve assessments that require nursing expertise. In-and-out catheterization, a sterile procedure, and calling reports to health care providers, which requires gathering and analysis of data, are responsibilities of the nurse. CN: Management of care; CL: Evaluate

98. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification? ■ 1. Class I. ■ 2. Class II. ■ 3. Class III. ■ 4. Class IV.

98. 2. According to the New York Heart Associa- tion Cardiac Disease classifi cation, this client would fi t under Class II because she is symptomatic with increased activity (dyspnea with exertion). The New York Heart Association Cardiac Disease Clas- sifi cation identifi es Class II clients as having cardiac disease and a slight limitation in physical activ- ity. When physical activity occurs, the client may experience angina, diffi culty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits. CN: Management of care; CL: Analyze

98. A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is dis- charged. In planning the family's care, an appropri- ate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following? ■ 1. Discuss how they will cope with twin infants at home. ■ 2. Participate in care of the twins as much as possible. ■ 3. Take turns providing 24-hour observation of the twins. ■ 4. Identify complications that may occur as the twins develop.

98. 2. It is important that the parents be allowed to touch, hold, and participate in care of the twins whenever they desire. Ideally, this will be on a daily basis, to promote parent-infant bonding. It is not appropriate to discuss how the couple will cope with twin infants at home until they are ready to take the infants home. They are too overwhelmed at this point and are focused on the well-being of their infants while hospitalized. Having the couple visit the twins to provide care on a 24-hour basis is not warranted. Identifying complications that may occur is not appropriate. If complications arise, the parents should be well informed and given opportu- nities for discussion related to the care provided. CN: Psychosocial adaptation; CL: Create

98. A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discom- fort. The nurse should: ■ 1. Place a cold pack on the client's perineal area. ■ 2. Place the client in a semi-Fowler's position. ■ 3. Notify the client's physician immediately. ■ 4. Ask the client to ambulate around the room.

98. 3. A positive Homan's sign, discomfort behind the knee or in the upper calf area on dorsifl exion of the foot, may be indicative of thrombophlebitis. Other signs include edema and redness at the site and may be more reliable as an indicator of thrombophlebitis. The nurse should notify the physician immediately and ask the client to remain in bed to minimize the risk for pulmo- nary embolus, a serious consequence of throm- bophlebitis should a clot dislodge. The Homan sign is observed on the client's legs, so placing an ice pack on the perineal area is inappropriate. However, ice to the perineum would be useful for episiotomy pain and swelling. The client does not need to be positioned in a semi-Fowler's position but should remain on bed rest to prevent dislodge- ment of a potential clot. CN: Reduction of risk potential; CL: Synthesize

98. A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the fi rst time that the parents visit the neonate in the nursery? ■ 1. Explain the surgical interventions that will be performed. ■ 2. Stress that this defect is not life-threatening. ■ 3. Emphasize the neonate's normal characteris- tics. ■ 4. Reassure the parents about the success rate of the surgery.

98. 3. On the initial visit, the parents may be shocked, fearful, and anxious. Nursing care should include spending time with the parents to allow them to express their emotions. The nurse should initially emphasize the neonate's normal charac- teristics. After the parents have had suffi cient time to adjust to the neonate's special needs, surgical interventions can be discussed. Telling the parents that this is not a life-threatening defect or that every- thing will be all right after the surgery is not helpful. Doing so discounts their feelings. Reassuring the parents about the success rate of the surgery can be done once the parents have had time to adjust to the neonate and express their emotions. CN: Psychosocial adaptation; CL: Synthesize

99. A primigravid client has completed her fi rst prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is posi- tive. The nurse can advise the client that the plan of care for this newborn will include? Select all that apply. ■ 1. Hepatitis B immune globulin at birth. ■ 2. Series of three hepatitis B vaccinations per recommended schedule. ■ 3. Hepatitis B screening when born. ■ 4. Isolation of infant during hospitalization. ■ 5. Universal precautions for mother and infant. ■ 6. Contraindication for breast-feeding because the mother is HBsAg positive.

99. 1, 2, 5. The test result indicates that the mother has an active hepatitis infection and is a car- rier. Hepatitis B immune globulin at birth provides the infant with passive immunity against hepatitis B and serves as a prophylactic treatment. Addi- tionally, the infant will be started on the vaccine series of three injections. The infant should not be screened or isolated because the infant is already hepatitis B positive. As with all clients, universal precautions should be used and are suffi cient to prevent transmission of the virus. Women who are positive for hepatitis B surface antigen are able to breast-feed. CN: Management of care; CL: Create

Managing Care Quality and Safety 99. Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see fi rst? ■ 1. A client at 13 weeks' gestation experiencing nausea and vomiting three times a day with +1 ketones in her urine. ■ 2. A client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day. ■ 3. A client at 32 weeks' gestation who has preec- lampsia and +3 proteinuria who is returning for evaluation of epigastric pain. ■ 4. A primigravida at 17 weeks' gestation com- plaining of not feeling fetal movement at this point in her pregnancy.

99. 3. A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at 13 weeks' gestation with nausea and vomiting is a concern be- cause the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the insulin-dependent diabetic. The insulin- dependent diabetic is a high priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need ad- ditional testing to further evaluate fetal well-being.) The primigravida who is at 17 weeks' gestation is too early in her pregnancy to experience fetal movement and would be the last person to be seen. CN: Management of care; CL: Evaluate

99. Prophylactic heparin therapy is ordered to treat thrombophlebitis in a multiparous client who delivered 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which of the following as the purpose of the drug? ■ 1. To thin the blood clots. ■ 2. To increase the lochial fl ow. ■ 3. To increase the perspiration for diuresis. ■ 4. To prevent further blood clot formation.

99. 4. Heparin therapy is ordered to prevent fur- ther clot formation by inhibiting further thrombus and clot formation. Heparin, an anticoagulant, does not make blood clots thinner. An adverse effect of heparin therapy during the puerperium is increased lochia fl ow, so the nurse must be observant for symptoms of hemorrhage, such as heavy lochial fl ow. Heparin does not increase diaphoresis, which is normal for the postpartum client. CN: Pharmacological and parenteral therapies; CL: Evaluate

99. A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client? ■ 1. Activity intolerance related to diffi cult labor process. ■ 2. Sleep deprivation related to prolonged labor. ■ 3. Situational low self-esteem related to lengthy labor process. ■ 4. Risk for infection related to birth trauma and prolonged ruptured membranes.

99. 4. The priority diagnosis is Risk for infec- tion related to birth trauma and prolonged ruptured membranes. Infection can be a serious postpartum complication. Although the client may be fatigued, she should not be experiencing activity intolerance. Clients with heart disease may experience activ- ity intolerance due to excessive cardiac workload. Although the client may be experiencing sleep deprivation, most clients are alert and awake after delivery of a newborn. Situational low self-esteem is not a priority diagnosis. Clients who undergo a cesarean delivery commonly feel a sense of failure because of not delivering vaginally, but this is not the case for this client. CN: Reduction of risk potential; CL: Analyze

88. A primigravid client in a Preparation for Par- enting class asks how much blood is lost during an uncomplicated delivery. The nurse should tell the woman: ■ 1. "The maximum blood loss considered within normal limits is 500 mL." ■ 2. "The minimum blood loss considered within normal limits is 1,000 mL." ■ 3. "Blood loss during a delivery is rarely esti- mated unless there is a hemorrhage." ■ 4. "It would be very unusual if you lost more than 100 mL of blood during the delivery."

CL: Apply 88. 1. In a normal delivery and for the fi rst 24 hours postpartum, a total blood loss not exceeding 500 mL is considered normal. Blood loss during delivery is almost always estimated because it pro- vides a valuable indicator for possible hemorrhage. A blood loss of 1,000 mL is considered hemorrhage. CN: Health promotion and maintenance; CL: Apply

Test 5

The Neonatal Client

The Post-Term Neonate 64. A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 min- utes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours post- partum. Which of the following nursing diagnoses would be the priority? ■ 1. Ineffective airway clearance related to post- term gestational age. ■ 2. Hyperthermia related to large size and use of a radiant warmer. ■ 3. Decreased cardiac output related to diffi cult delivery. ■ 4. Imbalanced nutrition: Less than body require- ments related to depleted glycogen stores.

The Post-Term Neonate 64. 4. Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the post-term neonate because of depleted glycogen stores. Therefore, Imbalanced nutrition: Less than body requirements is the priority nursing diagnosis. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the post-term neo- nate typically has diffi culty maintaining tempera- ture, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particu- larly because the neonate was delivered by cesar- ean delivery, which is not considered a diffi cult delivery. CN: Health promotion and maintenance; CL: Analyze

60. The nurse performed Leopold's maneuvers and determined that the fetal position is LOA. Identify the area where the nurse would place the Doppler to most easily hear fetal heart sounds.

pic 60. Because the fetus is determined to be in an LOA, a vertex position, the convex portion of the fetus lying closest to the uterine wall would be located in the lower left quadrant of the abdomen. Placing the Doppler ultrasound over that area would produce the loudest fetal heart sounds. CN: Management of care; CL: Apply

66. The nurse is teaching a woman who is 18 weeks pregnant about seat belt safety. Identify the area that indicates that the client understands where the lap portion of the seat belt should be placed.

pic 66. Seat belt safety is important for pregnant women because proper use reduces maternal mor- tality in car accidents. Both lap and shoulder belts are to be used. The lap portion of the belt is placed snugly but comfortably to fi t under the abdominal bulge. Wearing the lap belt over the abdomen could increase the risk of uterine rupture and fetal compli- cations due to belt tightening as the woman is pro- pelled forward during an automobile accident. The shoulder belt is placed snugly across the shoulder, chest, and upper abdomen. CN: Safety and infection control; CL: Apply

69. A nurse is eating lunch at a restaurant when she sees a pregnant woman showing signs of airway obstruction. When the nurse asks the woman if she needs help, the woman nods her head yes. Indicate the area where the nurse's fi st should be placed to effectively administer thrusts to clear the foreign body from the airway.

pic 69. The fi st is placed against the middle of the woman's sternum, with backward thrusts until the foreign body is expelled. The pressure from the backward thrusts causes compression of the ribs, further adding to the chest and lung pressure, thereby forcing the foreign body to move upward. CN: Safety and infection control; CL: Apply

83. The physician orders 1000 mL of Ringers Lac- tate intravenously over an 8-hour period for a 29-year- old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how may drops per minute? ____________________________ gtts/minute.

see dox

1. A laboring client with preeclampsia is pre- scribed magnesium sulfate 2 g/hour I.V. piggyback. The pharmacy sends the I.V. to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? ________________________ mL.

see dox solution CN: Pharmacological and parenteral therapies; CL: Apply