Maternity

During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? 1 Liver and raisins 2 Cheese and broccoli 3 Eggs and lean meats 4 Whole-wheat breads and cereals

During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? Correct2 Cheese and broccoli The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content. Although liver and raisins, eggs and lean meats, and whole-wheat breads and cereals are recommended as part of a high-quality nutritional intake, they are inadequate sources of calcium.

What is the nurse's priority assessment for a client in the fourth stage of labor? 1 Degree of relaxation 2 Distention of the bladder 3 Extent of breast engorgement 4 Presence of mother-infant bonding

What is the nurse's priority assessment for a client in the fourth stage of labor? Correct2 Distention of the bladder A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility.

What should supportive nursing care at the beginning of the mother-infant relationship include? 1 Suggesting that the mother choose breastfeeding instead of formula feeding 2 Advising the mother to engage in rooming-in with the newborn at the bedside 3 Encouraging the mother to help out with simple aspects of her newborn's care 4 Observing the mother-infant interaction unobtrusively to evaluate the relationship

What should supportive nursing care at the beginning of the mother-infant relationship include? 1 Suggesting that the mother choose breastfeeding instead of formula feeding 2 Advising the mother to engage in rooming-in with the newborn at the bedside Correct3 Encouraging the mother to help out with simple aspects of her newborn's care Incorrect4 Observing the mother-infant interaction unobtrusively to evaluate the relationship Holding, touching, and interacting with the newborn while providing basic care promotes attachment. The nurse's infant feeding preference should not be forced upon the mother. Although rooming-in helps promote attachment, not all women have the physical or emotional ability to provide 24-hour care to the newborn so early in the postpartum period. Early observation is not adequate; full evaluation of the relationship can be achieved only by allowing the mother ample time to interact with her baby.

A client at 10 weeks' gestation elects to have an induced abortion. After receiving oral mifepristone (Mifeprex), she returns to the clinic 2 days later to have misoprostol (Cytotec) inserted vaginally. How long after the procedure should the nurse have the patient return for a follow-up visit? 1 4 hours 2 8 to 24 hours 3 4 to 8 days 4 2 weeks

A client at 10 weeks' gestation elects to have an induced abortion. After receiving oral mifepristone (Mifeprex), she returns to the clinic 2 days later to have misoprostol (Cytotec) inserted vaginally. How long after the procedure should the nurse have the patient return for a follow-up visit? Correct4 2 weeks A follow-up visit 2 weeks later should confirm that the abortion has occurred. Four hours to 8 days after the procedure is too soon.

A client in labor states that she feels an urge to push. After a vaginal examination, the nurse determines that the cervix is 10 cm dilated. Which breathing pattern does the nurse encourage the client to use? 1 Expulsion breathing 2 Rhythmic chest breathing 3 Continuous blowing-breathing 4 Accelerated-decelerated breathing

A client in labor states that she feels an urge to push. After a vaginal examination, the nurse determines that the cervix is 10 cm dilated. Which breathing pattern does the nurse encourage the client to use? Correct1 Expulsion breathing 2 Rhythmic chest breathing Incorrect3 Continuous blowing-breathing 4 Accelerated-decelerated breathing Expulsion breathing (pushing) should not be encouraged until the cervix is fully dilated; doing it too early may cause cervical trauma and fatigue. A breathing pattern consisting of continuous blowing can assist in overcoming the urge to push when a client is in transition. Rhythmic chest breathing is used in the early active phase of labor for relief of discomfort; it is not used to overcome the desire to push. Accelerated-decelerated breathing is not effective in overcoming the urge to push.

A nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect? 1 Bulging perineum 2 Pinkish vaginal discharge 3 Crowning of the fetal head 4 Rectal pressure during contractions

A nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect? Correct4 Rectal pressure during contractions Rectal pressure occurs at the beginning of the transition phase of labor when the fetal head starts to press on the rectum during contractions. The perineum bulges when transition is complete and the cervix is fully dilated. Pink vaginal discharge occurs when labor begins, not at the beginning of the transition phase. The fetal head crowns at the end of the second stage, shortly before birth.

A nurse suspects cephalopelvic disproportion in a client who is having a difficult labor. For which test should the nurse prepare the client? 1 Ultrasound 2 Fetal scalp pH 3 Amniocentesis 4 Digital pelvimetry

A nurse suspects cephalopelvic disproportion in a client who is having a difficult labor. For which test should the nurse prepare the client? Correct1 Ultrasound 2 Fetal scalp pH 3 Amniocentesis Incorrect4 Digital pelvimetry A sonogram of the pelvis is an accurate and safe test for cephalopelvic disproportion. Fetal scalp pH is performed to assess fetal well-being. Amniocentesis is a test of the components of the amniotic fluid; it does not reveal the size of the fetus or the diameter of the pelvis. Digital pelvimetry is an external measurement obtained by the health care provider; it is an estimate, not an accurate assessment.

A postpartum client tells the nurse, "I was just told that I have an erosion of the cervix. What could have caused this?" What is the nurse's best reply? 1 "Your labor was long and difficult." 2 "The acidity of your vagina is altered." 3 "Your cervical opening was stretched during birth, resulting in lacerations." 4 "The effacement and dilation of the cervix were not complete at the time of birth."

A postpartum client tells the nurse, "I was just told that I have an erosion of the cervix. What could have caused this?" What is the nurse's best reply? 1 "Your labor was long and difficult." Correct2 "The acidity of your vagina is altered." 3 "Your cervical opening was stretched during birth, resulting in lacerations." Incorrect4 "The effacement and dilation of the cervix were not complete at the time of birth." Changes in the pH of the vaginal tract cause cellular alteration and destruction; erosion involves continuous inflammation or ulceration. The direct effects of labor and birth do not cause cervical erosion; erosion involves continuous inflammation or ulceration.

Twelve hours after delivery the nurse is checking the client. Where does the nurse expect to find the fundus once the woman has voided?

At twelve hours post-delivery, the uterus should be midline, slightly above the umbilicus.

During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal infection because of the presence of a white curdlike vaginal discharge. What other assessment supports a fungal vaginal infection? 1 A foul odor 2 An itchy perineum 3 An ischemic cervix 4 A forgotten tampon

During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal infection because of the presence of a white curdlike vaginal discharge. What other assessment supports a fungal vaginal infection? Incorrect1 A foul odor Correct2 An itchy perineum 3 An ischemic cervix 4 A forgotten tampon An itchy perineum usually occurs with candidiasis, a fungal infection; pruritus is the most common symptom. An odorous, frothy greenish discharge occurs with trichomoniasis, a protozoal infestation. Ischemia of the cervix is not associated with candidiasis; candidiasis causes vaginal and cervical inflammation. A forgotten tampon may cause bacterial, not fungal, vaginitis.

Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? 1 Facial redness and an urge to push 2 Bulging perineum, crowning, and caput 3 Less intense, less frequent contractions 4 Increased bloody show, irritability, and shaking

Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? Correct4 Increased bloody show, irritability, and shaking Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. Bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.

On a 6-week postpartum visit a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for: 1 Fat and calcium 2 Vitamin C and iron 3 Thiamine and sodium 4 Protein and carbohydrates

On a 6-week postpartum visit a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for: Incorrect1 Fat and calcium Correct2 Vitamin C and iron 3 Thiamine and sodium 4 Protein and carbohydrates Whole milk does not meet the infant's need for vitamin C and iron. It contains adequate fats, but the calcium content is 3½ times that of human milk. Whole milk contains adequate thiamine, but the sodium content is 3 times that of human milk. Whole milk contains adequate carbohydrates, but the protein content is 3 times that of human milk.

Which finding indicates the development of a complication resulting from the presence of bilateral cephalhematomas? 1 Urine output 2 Skin color 3 Glucose level 4 Rooting/sucking reflex

Which finding indicates the development of a complication resulting from the presence of bilateral cephalhematomas? Correct2 Skin color Cephalhematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice may result. Glucose level, urine output, and the rooting/sucking reflex are not affected by a cephalhematoma.

Before administering Rho(D) immune globulin (RhoGAM), a nurse reviews a pregnant client's laboratory data. What combination of factors in the blood directs the need for RhoGAM? 1 Rh positivity and a positive Coombs test result 2 Rh negativity and a positive Coombs test result 3 Rh positivity and a negative Coombs test result 4

Before administering Rho(D) immune globulin (RhoGAM), a nurse reviews a pregnant client's laboratory data. What combination of factors in the blood directs the need for RhoGAM? 1 Rh positivity and a positive Coombs test result Incorrect2 Rh negativity and a positive Coombs test result 3 Rh positivity and a negative Coombs test result Correct4 Rh negativity and a negative Coombs test result Rho(D) immune globulin (RhoGAM) is administered to prevent active formation of antibodies when an Rh-negative individual is at risk for sensitization. RhoGAM is contraindicated in Rh-positive women because it will cause hemolysis of red blood cells; it is never given to an individual with Rh antibodies. A positive Coombs test result indicates that the woman has Rh antibodies. RhoGAM never is given to an individual with Rh antibodies. RhoGAM is contraindicated in Rh-positive women because it will cause hemolysis of red blood cells.

A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. While taking the nursing history the nurse expects the client to state that one of the reasons she is having surgery is because she has been experiencing: 1 Hematuria 2 Dysmenorrhea 3 Pain on urination 4 Stress incontinence

A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. While taking the nursing history the nurse expects the client to state that one of the reasons she is having surgery is because she has been experiencing: Correct4 Stress incontinence Increased intraabdominal pressure associated with lifting, coughing, or laughing, in conjunction with a relaxed pelvic musculature and a bladder displaced into the vagina, results in inability to suppress urination. Hematuria is usually associated with urinary tract infection, bladder tumor, or renal calculi, not with cystocele or rectocele. Dysmenorrhea is usually associated with pelvic inflammatory disease, endometriosis, or cervical stenosis, not with cystocele or rectocele; the client is probably postmenopausal. Pain on urination is usually associated with urinary infection, not with cystocele or rectocele.

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. 1 "My ears are ringing." 2 "It gets better when I lie down." 3 "Bright lights really bother my eyes." 4 "It gets better as soon as I walk a while." 5 "My head hurts more when I'm sitting watching TV." 6 "My head hurts more when I'm lying on my side breastfeeding."

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. Correct 1 "My ears are ringing." Correct 2 "It gets better when I lie down." Correct 3 "Bright lights really bother my eyes." Correct 5 "My head hurts more when I'm sitting watching TV." Central nervous system irritation can cause auditory problems such as tinnitus. A headache resulting from spinal anesthesia usually occurs 24 to 72 hours after administration. Postural changes cause the diminished volume of cerebrospinal fluid to exert traction on pain-sensitive central nervous system structures. The client is most comfortable when lying flat. Central nervous system irritation can cause visual problems such as photophobia and blurred vision. This type of headache will worsen when the client is ambulatory or assumes an upright position.

A female client asks a nurse about using an intrauterine device (IUD) for contraception. When explaining this method, what common problem should the nurse include in the discussion? 1 The device can be expelled. 2 The uterus may be perforated. 3 Discomfort during intercourse may occur. 4 Vaginal infections are frequent consequences.

A female client asks a nurse about using an intrauterine device (IUD) for contraception. When explaining this method, what common problem should the nurse include in the discussion? Correct1 The device can be expelled. The IUD may cause irritability of the myometrium, inducing uterine contractions and expulsion of the device; the presence of the IUD thread should be verified after menstruation and before coitus. A perforated uterus is a rare, rather than a common, occurrence. It is not common to have discomfort during coitus (dyspareunia) with an IUD in place; this is one of the warning signs that should be reported. Frequent vaginal infections do not occur with an IUD; if an infection should occur, it usually begins within the first 20 days after insertion.

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client? 1 Fewer contractions 2 Depressed respirations 3 Decreased blood pressure 4 Accumulated respiratory secretions

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client? Correct3 Decreased blood pressure Mild reactions, including vertigo, dizziness, and hypotension, occur because of vasodilation resulting from direct action of these medications on the mother's pelvic blood vessels. The progress of labor is not affected by a local anesthetic administered during the second stage of labor. A local anesthetic does not affect the respiratory center in the central nervous system. Accumulated respiratory secretions are not caused by a local anesthetic administered during the second stage of labor.

A male adolescent with cystic fibrosis (CF) whose parents are both carriers of the disease asks a nurse, "When I have children, could they have cystic fibrosis like me?" On what information about men with CF should the nurse base the response? 1 Generally they have a 50% chance of having children with the disease. 2 Usually they are unable to father children, although sexual function is not affected. 3 They have a greater chance of passing the disease to their children if their parents are carriers. 4 They do not pass this disease to their children because it is carried on the female sex chromosome.

A male adolescent with cystic fibrosis (CF) whose parents are both carriers of the disease asks a nurse, "When I have children, could they have cystic fibrosis like me?" On what information about men with CF should the nurse base the response? Correct2 Usually they are unable to father children, although sexual function is not affected. Failure of the vas deferens, epididymis, and seminal vesicles to develop, or blockage of the vas deferens with viscous secretions, means that sperm production in CF is decreased or absent, and therefore most men with CF are sterile. CF is inherited as an autosomal recessive trait; it is not sex linked.

A male infant born at 35 weeks' gestation is in the neonatal intensive care unit (NICU). When the mother is told that her infant's condition is now stable, she asks, "When will I be able to breastfeed my son?" How should the nurse respond? 1 "Even though he's preterm, his condition is stable. You may try now, if you like." 2 "Preterm infants shouldn't breastfeed. It takes more energy than formula feeding." 3 "Pump your breasts now, and then feed him the milk in a bottle with a preemie nipple." 4 "Because he's preterm and sucks weakly, it'll be several weeks before you'll be able to breastfeed."

A male infant born at 35 weeks' gestation is in the neonatal intensive care unit (NICU). When the mother is told that her infant's condition is now stable, she asks, "When will I be able to breastfeed my son?" How should the nurse respond? Correct1 "Even though he's preterm, his condition is stable. You may try now, if you like." A preterm infant may have a weak suck but usually can be breastfed; the mother should attempt it if the infant's condition is stable. It does not necessarily take more calories to breastfeed; also, there are immunological benefits for the preterm infant who is receiving antibodies from breast milk. Pumping the breasts may be necessary, but at 35 weeks if the infant is stable and the mother so desires, breastfeeding may be attempted. The suck may or may not be weak, but a supervised attempt to breastfeed should be encouraged.

A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time? 1 Checking cervical dilation every hour 2 Keeping the labor environment dark and quiet 3 Infusing oxytocin by piggybacking into the primary line 4 Positioning the client on the left side throughout the infusion

A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time? 1 Checking cervical dilation every hour Incorrect2 Keeping the labor environment dark and quiet Correct3 Infusing oxytocin by piggybacking into the primary line 4 Positioning the client on the left side throughout the infusion Piggybacking the oxytocin (Pitocin) infusion allows it to be discontinued, if necessary, while permitting the vein to remain open by way of the primary IV. Cervical dilation is checked when there is believed to be a change, not on a regular basis. Unless specifically requested by the client, there is no reason to maintain a dark, quiet labor environment. Although positioning the client on her left side is recommended, it is not the primary concern at this time; there are no data to indicate maternal hypotension.

A nurse is assessing a female client with suspected primary syphilis. What sign of primary syphilis does the nurse expect the client to exhibit? 1 Flat wartlike plaques around the vagina and anus 2 An indurated painless nodule on the vulva that is draining 3 Glistening patches in the mouth covered with a yellow exudate 4 A maculopapular rash on the palms of the hands and soles of the feet

A nurse is assessing a female client with suspected primary syphilis. What sign of primary syphilis does the nurse expect the client to exhibit? Incorrect1 Flat wartlike plaques around the vagina and anus Correct2 An indurated painless nodule on the vulva that is draining 3 Glistening patches in the mouth covered with a yellow exudate 4 A maculopapular rash on the palms of the hands and soles of the feet This is the description of a chancre, which is the initial sign of syphilis. Flat wartlike plaques around the vagina and anus are condylomata, which are typical of the secondary stage of syphilis. Glistening patches in the mouth covered with a yellow exudate are typical of the secondary stage of systemic involvement, which occurs from 2 to 4 years after the disappearance of the chancre. A maculopapular rash on the palms and soles is typical of the secondary stage.

A nurse is assessing clients on the postpartum unit for pain. The client who will have more severe afterbirth pains is one who: 1 Is a grand multipara 2 Is a breastfeeding primipara 3 Had a vaginal birth for a first pregnancy 4 Had a cesarean birth at 43 weeks' gestation

A nurse is assessing clients on the postpartum unit for pain. The client who will have more severe afterbirth pains is one who: Correct1 Is a grand multipara A multipara's uterus tends to contract and relax spasmodically, even if the uterine tone is effective, resulting in pain that may require an analgesic for relief. Although breastfeeding increases the contractile state of the postpartum uterus, the breastfeeding primipara will not have the typical afterbirth pains of a multipara. Primiparas are less likely to have afterbirth pains than are multiparas. A cesarean birth has no effect on the development of afterbirth pains.

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply. 1 Prone 2 Sitting 3 Supine 4 Lateral 5 Knee-chest

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply. Incorrect1 Prone Correct2 Sitting 3 Supine Correct4 Lateral Correct5 Knee-chest The sitting position relieves back pain because it removes pressure from the back. The lateral position relieves back pain because it removes pressure from the back. The knee-chest position may help relieve back pain because it removes pressure from the back. The prone position is almost impossible to assume because of the size of the uterus; also, it cannot be maintained because it impedes fetal monitoring. Low back pain is aggravated when the client is in the supine position because of increased pressure from the fetus on the lumbar and sacral regions.

A nurse is caring for a primigravida during labor. What does the nurse note that indicates that birth is about to take place? 1 Bloody discharge from the vagina is increasing. 2 The perineum has begun to bulge with each contraction. 3 The client becomes irritable and stops following instructions. 4 Contractions occur more frequently, are stronger, and last longer.

A nurse is caring for a primigravida during labor. What does the nurse note that indicates that birth is about to take place? correct 2 The perineum has begun to bulge with each contraction. The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent. An increase in bloody show and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage.

A nurse is obtaining the health history from a 21-year-old client who is seeking contraceptive information. What factor in the client's history is a contraindication to the use of oral contraceptives? 1 History of hypertension 2 Pack-a-day cigarette habit 3 Older than 30 years of age 4 Several multiple pregnancies

A nurse is obtaining the health history from a 21-year-old client who is seeking contraceptive information. What factor in the client's history is a contraindication to the use of oral contraceptives? Correct1 History of hypertension 2 Pack-a-day cigarette habit 3 Older than 30 years of age Incorrect4 Several multiple pregnancies Oral contraceptives may increase blood pressure; they are contraindicated if the client's blood pressure is 160/100 mm Hg. Although clients should be cautioned strongly against smoking, this is not a contraindication if they are younger than 35 years of age. Oral contraceptives are contraindicated in women older than 35 years if they smoke more than 15 cigarettes a day. There is no relationship between oral contraceptives and multiple births.

A nurse is planning care for a client who gave birth to a preterm male infant. What most common response does the nurse anticipate that the mother may experience? 1 Feelings of failure and loss of control 2 Thoughts related to guilt and withdrawal 3 Fear of forming a healthy relationship with her son until he is out of danger 4 Need for increased attachment behaviors because of her son's life-threatening condition

A nurse is planning care for a client who gave birth to a preterm male infant. What most common response does the nurse anticipate that the mother may experience? Correct1 Feelings of failure and loss of control 2 Thoughts related to guilt and withdrawal 3 Fear of forming a healthy relationship with her son until he is out of danger Incorrect4 Need for increased attachment behaviors because of her son's life-threatening condition Attachment theory states that the experience of the birth of a preterm infant carries with it feelings of loss of control for the mother. Withdrawal from the situation is maladaptive and requires special help. A healthy relationship may develop regardless of the infant's health. There is no basis to believe that increased attachment behaviors are needed.

A nurse is teaching a class of expectant parents about potential complications that may indicate the need for a cesarean birth. What common indication for a cesarean birth should the nurse discuss? 1 Placenta previa 2 Primary uterine inertia 3 Incompetent cervical os 4 Cephalopelvic disproportion

A nurse is teaching a class of expectant parents about potential complications that may indicate the need for a cesarean birth. What common indication for a cesarean birth should the nurse discuss? Incorrect1 Placenta previa 2 Primary uterine inertia 3 Incompetent cervical os Correct4 Cephalopelvic disproportion Statistically, cephalopelvic disproportion is the most common indication for a first-time cesarean birth. Unless the placenta covers the os or hemorrhage occurs, vaginal birth is preferred. Primary uterine inertia may be improved by rest and hydration followed by an infusion of oxytocin (Pitocin), which promotes vaginal birth. Incompetent cervical os is more likely to cause a preterm birth.

A nurse is teaching arm exercises to a woman who has undergone a right mastectomy. The nurse instructs the client to: 1 Wear a sling between exercise periods. 2 Exercise the right arm before the left arm. 3 Perform exercises with both arms simultaneously when possible. 4 Wait until the drain has been removed before starting the exercises.

A nurse is teaching arm exercises to a woman who has undergone a right mastectomy. The nurse instructs the client to: Incorrect1 Wear a sling between exercise periods. 2 Exercise the right arm before the left arm. Correct3 Perform exercises with both arms simultaneously when possible. 4 Wait until the drain has been removed before starting the exercises. Postmastectomy exercises should be bilateral, involving the use of both arms simultaneously, when possible, to prevent shortening of muscles and contracture of joints. A sling immobilizes the arm, resulting in joint stiffness and loss of muscle tone. Exercises are usually started within 24 hours of surgery to prevent contractures and muscle atony of the affected arm.

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? 1 Heavy vaginal bleeding 2 Fetal heart rate irregularities 3 Greenish-tinged amniotic fluid 4

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? Correct3 Greenish-tinged amniotic fluid Greenish amniotic fluid is common in a breech presentation because the contracting uterus exerts pressure on the fetus's lower colon, forcing the expulsion of meconium. Mild bloody show is expected; a heavier flow is a deviation from the expected response and not a common finding with breech presentations. Fetal heart rate irregularities are not specific to a breech presentation. Severe back pain is more likely to occur when the fetus is in a cephalic presentation and the occiput is in the posterior position.

A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. A licensed practical nurse/licensed vocational nurse (LPN/LVN) and aide are also working on the unit. Which nursing action is best delegated to the LPN/LVN? 1 Discharge teaching for a client who delivered her third infant girl 2 days ago 2 Delivering a clear-liquid dietary tray to a client who had a cesarean section 4 hours ago 3 Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 4 The initial assessment of a client who just delivered an 8 lb 12 oz (3970 g) infant over an intact perineum

A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. A licensed practical nurse/licensed vocational nurse (LPN/LVN) and aide are also working on the unit. Which nursing action is best delegated to the LPN/LVN? Correct3 Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 The pain assessment has been performed and the RN will need to evaluate the effectiveness of the pain medication. However, the administration of oral pain medication is within the scope of practice for an LPN/LVN. Initial teaching and assessment are within the scope of practice for only the RN and may only be delegated to another RN. A meal tray may be delivered by an unlicensed person such as an aide or a dietary employee.

A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? 1 Early first stage of labor 2 Transition stage of labor 3 Beginning second stage labor 4 Midway through first stage of labor

A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? Correct4 Midway through first stage of labor The cervix is 90% effaced and dilated 6 cm during the active phase of the first stage of labor. When the cervix is dilated 6 cm, the individual is beyond the early stage of labor. Transition is not a stage of labor; it is the last phase of the first stage of labor, which begins when the cervix is dilated 8 cm. The second stage of labor begins when the cervix is fully dilated and 100% effaced.

After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate (Clomid) is prescribed. The nurse concludes that the client understands the teaching about the correct time to take the clomiphene when the she states, "I'll start the pills on the: 1 Fifth day of my cycle" 2 Last day of my period" 3 Third day after my period" 4 16th day of my cycle"

After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate (Clomid) is prescribed. The nurse concludes that the client understands the teaching about the correct time to take the clomiphene when the she states, "I'll start the pills on the: Correct1 Fifth day of my cycle" I The objective is to stimulate ovulation near the 14th day of the menstrual cycle, and this is achieved by taking the medication on the fifth through the ninth days; there is an increase in two pituitary gonadotropins luteinizing hormone and follicle-stimulating hormone, with subsequent ovarian stimulation. On the third day after the cycle there are insufficient hormones for clomiphene to be effective. The 16th day of the cycle is also too late for clomiphene to be effective.

After a client has been in labor for 6 hours at home, she is admitted to the birthing room. The client is dilated 5 cm and at −1 station. In the next hour her contractions gradually become irregular and are more uncomfortable. Which possibility should the nurse consider first? 1 The client is in false labor. 2 The client has a full bladder. 3 There is uterine dysfunction. 4 There is a breech presentation.

After a client has been in labor for 6 hours at home, she is admitted to the birthing room. The client is dilated 5 cm and at −1 station. In the next hour her contractions gradually become irregular and are more uncomfortable. Which possibility should the nurse consider first? Correct2 The client has a full bladder. A full bladder can impede the forces of labor, and so it must be emptied before any other assessment can be made accurately. The client's cervix is dilating, and therefore she is in true, not false, labor. Before the possibility of uterine dysfunction is considered, the client's bladder should be emptied to relieve the pressure of the bladder on the uterus; the client should then be observed to determine whether regular contractions have resumed. The existence of a breech presentation should have been established during the admission examination.

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication? 1 Early phase 2 Active phase 3 Transition phase 4 Expulsion phase

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication? 1 Early phase Correct2 Active phase Incorrect3 Transition phase 4 Expulsion phase Respiratory depression of the newborn will not occur if the medication is given during the active phase; it should not be given when birth is expected to occur within 2 hours. The level of pain during the early phase can usually be managed with other strategies such as breathing techniques or diversion; giving an opioid early in labor may slow the progress of labor. An opioid should be avoided in the 2 hours preceding birth; giving it to a client in the transition phase can cause respiratory depression in the newborn. Giving the medication when birth is imminent is contraindicated because it may cause respiratory depression in the newborn; the mother's level of consciousness will be altered as well, making it difficult for her to cooperate with requests for her to push.

During labor a client who is receiving epidural anesthesia has an episode of severe nausea, and her skin becomes pale and clammy. What is the immediate nursing action? 1 Elevating the legs 2 Notifying the practitioner 3 Checking for vaginal bleeding 4 Monitoring the frequency of contractions

During labor a client who is receiving epidural anesthesia has an episode of severe nausea, and her skin becomes pale and clammy. What is the immediate nursing action? Correct1 Elevating the legs Maternal hypotension is a common complication of epidural anesthesia, and nausea is one of the first clues that it has occurred; elevating the lower extremities restores blood volume to the central circulation. If signs and symptoms do not abate after elevation of the legs, the practitioner should be notified. Checking for vaginal bleeding and monitoring the frequency of contractions are not specific observations associated with the administration of anesthesia; they are each part of the general nursing care during labor.

The nurse is caring for a couple during their initial visit to a fertility clinic after being unable to conceive for 2 years. Which of the following assessment questions would be appropriate to determine an alternate cause of infertility? 1 "Do you use any lubrication during intercourse?" 2 "Can both of you reach orgasm at the same time?" 3 "What type of birth control did you use in the past?" 4 "Are you consistent in the manner in which you have intercourse?"

The nurse is caring for a couple during their initial visit to a fertility clinic after being unable to conceive for 2 years. Which of the following assessment questions would be appropriate to determine an alternate cause of infertility? Correct1 "Do you use any lubrication during intercourse?" 2 "Can both of you reach orgasm at the same time?" Incorrect3 "What type of birth control did you use in the past?" 4 "Are you consistent in the manner in which you have intercourse?" Some lubricants act as a spermicide; they should be avoided, or only a recommended one should be used. A female orgasm is not necessary for conception; simultaneous orgasms is not relevant. The type of birth control used 2 years before the couple began trying to conceive is not relevant at this time; some hormonal contraceptives should be discontinued 6 to 18 months before trying to conceive. Consistency in the manner of intercourse usually is not relevant to conception, although a change in position may be recommended.

The nurse is teaching a client who is scheduling a vasectomy. What information is essential that the nurse explain to the client? 1 Recanalization of the vas deferens is impossible. 2 Unprotected coitus is safe within 1 week to 10 days. 3 Some impotency is to be expected for several weeks after the procedure. 4 At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

The nurse is teaching a client who is scheduling a vasectomy. What information is essential that the nurse explain to the client? Correct4 At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked. Some spermatozoa will remain viable in the vas deferens for a variable time after vasectomy. There has been some success in reversing vasectomy. Precautions must be taken to prevent fertilization until absence of sperm in the semen has been verified. The procedure does not affect sexual function.

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? 1 Clopidogrel (Plavix) 2 Warfarin (Coumadin) 3 Continuous infusion of heparin 4 Intermittent doses of a low-molecular-weight heparin

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? Correct3 Continuous infusion of heparin Heparin is the medication of choice during the acute phase of a deep vein thrombosis; it prevents conversion of fibrinogen to fibrin and of prothrombin to thrombin. Clopidogrel (Plavix) is a platelet aggregate inhibitor and is used to reduce the risk of a brain attack. Warfarin (Coumadin), a long-acting oral anticoagulant, is started after the acute stage has subsided; it is continued for 2 to 3 months. A low molecular weight heparin (e.g., enoxaparin [Lovenox]) is not administered during the acute stage; it may be administered later to prevent future deep vein thromboses.

Two days after giving birth a client's temperature is 101° F (38.3° C). A nurse notifies the health care provider and receives a variety of prescriptions. In what order should they be implemented? 1. Offer the as-needed acetaminophen (Tylenol) for a fever more than 100° F (37.7° C). 2. Assess and document the client's temperature 30 minutes after administering the medications. 3. Send a lochia specimen for culture. 4. Administer the prescribed intravenous antibiotic. 5. Obtain a chest x-ray.

Two days after giving birth a client's temperature is 101° F (38.3° C). A nurse notifies the health care provider and receives a variety of prescriptions. In what order should they be implemented? A culture specimen should be obtained before antibiotics are given to ensure that the antibiotic does not interfere with accurate culture results. The antibiotic is the most important of these prescriptions and should be given as soon as possible to counteract any infective processes, but it should not be administered before the specimen is obtained for the culture. The acetaminophen (Tylenol) is a comfort measure that may be administered at any time, but does not take precedence over the antibiotic, however, it would facilitate pain relief prior to obtaining a chest x-ray which would require additional movement and possibly increased discomfort. Arranging for a chest radiograph will not interfere with implementation of any of the other prescriptions; it may take time to schedule a radiograph. The client's response to the acetaminophen should have lowered the client's temperature within 30 minutes.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply. 1 Pain management with oral analgesics 2 Continuous application of a warm pack 3 Assessment of the site every 15 minutes 4 Gentle cleansing with antibacterial cleanser 5 Application of an ice pack for 20-minute intervals 6 Instructing the client in how to promote normal bowel function Providing pain management will prevent the client's pain from reaching an unmanageable level.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply. Correct 1 Pain management with oral analgesics Correct 3 Assessment of the site every 15 minutes Correct 5 Application of an ice pack for 20-minute intervals Providing pain management will prevent the client's pain from reaching an unmanageable level. Application of ice will decrease pain and edema. Assessment of the site will identify any abnormal changes. Warmth applied to newly traumatized tissue will increase pain and edema. Antibacterial cleanser would be caustic and painful to the laceration. Teaching regarding bowel function would be more appropriately presented after the client has completed the fourth stage and resumed normal intake.

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period? 1 Bradycardia with no change in respirations 2 Tachycardia with a decrease in respirations 3 Increased basal temperature with a decrease in respirations 4 Decreased basal temperature with an increase in respirations

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period? Correct1 Bradycardia with no change in respirations In the postpartum period a slow pulse rate may result from a combination of factors, including decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth. Bradycardia is more likely; respirations generally are unchanged. The temperature may rise slightly, but usually respirations are unchanged.

What nursing care is required for a client with a radium implant for cancer of the cervix? 1 Spending time with the client to alleviate her anxiety 2 Wearing a lead-lined apron for self-protection while in the room 3 Limiting the client's activity to avoid dislodging the radium insert 4 Using disposable sheets for protection from exposure to laundry personnel

What nursing care is required for a client with a radium implant for cancer of the cervix? Correct3 Limiting the client's activity to avoid dislodging the radium insert Activity must be limited so the implant will not be dislodged. While the client is receiving therapy, alpha, beta, and gamma rays will be emitted; therefore the nurse should employ the principles of time and distance when providing care. The extent of exposure to the client must be monitored and kept within safe limits, depending on the type and quantity of rays emitted. Wearing a lead-lined apron for self-protection while the nurse in the room is not necessary; adherence to principles of time and distance will protect the nurse from excessive exposure. Using disposable sheets for protection from exposure to laundry personnel is not necessary; however, all bed linens must be examined carefully for dislodged radium implants before the linens are sent to the laundry.

fter being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. During the assessment the nurse notes that the fetus's head has emerged. How should the nurse assist the mother in 1 Gently guiding the head downward 2 Gradually flexing the head toward the mother's thigh 3 Gently putting pressure on the head by pulling upward 4 Gradually extending the head above the mother's symphysis pubis

fter being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. During the assessment the nurse notes that the fetus's head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder? Correct1 Gently guiding the head downward After the newborn's head has rotated externally, the nurse gently guides the head downward for the birth of the anterior shoulder. Gradually flexing the head toward the mother's thigh, gently putting pressure on the head by pulling upward, and gradually extending the head above the mother's symphysis pubis are all contraindicated. 47%of students nationwide answered this question correctly.