Maternity & Newborn Nursing - Ricii - Ch's 11-22

Chapter 16, 1 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 446 226. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.

A Response: As a result of the changes in blood volume and cardiac output after delivery, relative bradycardia may be noted. The woman's pulse rate may range from 50 to 70 beats per minute.

Chapter 15, 4 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 430 214. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus

A Response: By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

Chapter 17, 8 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 484 8. After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket.

A Response: Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

Chapter 11, 11 Format: Multiple Selection Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 289 162. A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? Select all that apply. A) Positive pregnancy test B) Ultrasound visualization of the fetus C) Auscultation of a fetal heart beat D) Ballottement E) Absence of menstruation F) Softening of the cervix

A, D, F Response: Probable signs of pregnancy include a positive pregnancy test, ballottement, and softening of the cervix (Goodell's sign). Ultrasound visualization of the fetus, auscultation of a fetal heart beat, and palpation of fetal movements are considered positive signs of pregnancy. Absence of menstruation is a presumptive sign of pregnancy.

Chapter 14, 16 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 388 210. When palpating the fundus during a contraction, the nurse notes that is feels like a chin. The nurse interprets this finding as indicating which type of contraction? A) Intense B) Strong C) Moderate D) Mild

C Response: A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong contraction feels like the forehead.

Chapter 13, 2 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 6 Page: 379 183. Which of the following would indicate to the nurse that the placenta is separating? A) Uterus becomes globular B) Fetal head at vaginal opening C) Umbilical cord shortens D) Mucous plug is expelled

A Response: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.

Chapter 11, 9 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Easy Integrated Processes: Nursing Process Objective: 5 Page: 307 160. When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find? A) Ambivalence B) Introversion C) Acceptance D) Emotional lability

A Response: During the first trimester, the pregnant woman commonly experiences ambivalence, with conflicting feelings at the same time. Introversion heightens during the first and third trimesters when the woman's focus is on behaviors that will ensure a safe and healthy pregnancy outcome. Acceptance usually occurs during the second trimester. Emotional lability (mood swings) is characteristic throughout a woman's pregnancy.

Chapter 14, 15 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 8 Page: 421 209. Which of the following is a priority when caring for a woman during the fourth stage of labor? A) Assessing the uterine fundus B) Offering fluids as indicated C) Encouraging the woman to void D) Assisting with perineal care

A Response: During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

Chapter 14, 3 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 9 Page: 414 197. A woman has just entered the second stage of labor. The nurse would focus care on which of the following? A) Encouraging the woman to push when she has a strong desire to do so B) Alleviating perineal discomfort with the application of ice packs C) Palpating the woman's fundus for position and firmness D) Completing the identification process of the newborn with the mother

A Response: During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.

Chapter 15, 8 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Caring Objective: 3 Page: 437 218. The nurse interprets which of the following as evidence that a client is in the taking-in phase? A) Client states, "He has my eyes and nose." B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newborn.

A Response: During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.

Chapter 14, 4 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 5 Page: 395 198. The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next? A) Continue to monitor the FHR because this pattern is benign. B) Perform a vaginal exam to assess cervical dilation and effacement. C) Stay with the client while reporting the finding to the physician. D) Administer oxygen after turning the client on her left side.

A Response: Early decelerations are not indicative of fetal distress and do not require intervention. Therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal exam, report the finding to the physician, or administer oxygen.

Chapter 15, 13 Format: Multiple Choice Chapter: 15 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 430 223. A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? A) Early ambulation B) Prolonged labor C) Large fetus D) Use of anesthetics

A Response: Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.

Chapter 17, 7 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Caring Objective: 4 Page: 492 7. A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation

A Response: From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

Chapter 13, 13 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Application Difficulty: Easy Integrated Processes: Nursing Process Objective: 3 Page: 367 194. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A) Frank B) Full C) Complete D) Footling

A Response: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

Chapter 11, 15 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Communication and Documentation Objective: 3 Page: 296 166. Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which of the following? A) Linea nigra B) Striae gravidarum C) Melasma D) Vascular spiders

A Response: Linea nigra refers to the darkened line of pigmentation down the middle of the abdomen in pregnant women. Striae gravidarum refers to stretch marks, irregular reddish streaks on the abdomen, breasts, and buttocks. Melasma refers to the increased pigmentation on the face, also known as the "mask of pregnancy." Vascular spiders are small, spiderlike blood vessels that appear usually above the waist and on the neck, thorax, face, and arms.

Chapter 14, 11 Format: Multiple Choice Chapter: 14 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 6 Page: 404 205. A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following? A) Respiratory depression B) Urinary retention C) Abdominal distention D) Hyperreflexia

A Response: Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

Chapter 16, 12 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 4 Page: 449 237. When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A) Early parent-infant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth

A Response: Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

Chapter 12, 1 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Communication and Documentation Objective: 5 Page: 344 167. A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband." The woman's pregnancy has been uneventful. The nurse responds based on the understanding that: A) It is safe to have intercourse at this time B) Intercourse at this time is likely to cause rupture of membranes C) There are other ways that the couple can satisfy their needs D) Intercourse at this time is likely to result in premature labor

A Response: Sexual activity is permissible during pregnancy unless there is a history of vaginal bleeding, placenta previa, risk of preterm labor, multiple gestation, incompetent cervix, premature rupture of membranes, or presence of infection. Rupture of membranes or premature labor is unlikely since the woman's pregnancy has been uneventful so far. Alternative sexual positions may be necessary as the woman's abdomen increases in size.

Chapter 11, 4 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 291 155. In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse explains that this is due to: A) Pressure of the gravid uterus on the vena cava B) A 50% increase in blood volume C) Physiologic anemia due to hemoglobin decrease D) Pressure of the presenting fetal part on the diaphragm

A Response: The client is describing symptoms of supine hypotension syndrome, which occurs when the heavy gravid uterus falls back against the superior vena cava in the supine position. The vena cava is compressed, reducing venous return, cardiac output, and blood pressure, with increased orthostasis. The increased blood volume and physiologic anemia are unrelated to the client's symptoms. Pressure on the diaphragm would lead to dyspnea.

Chapter 13, 7 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 366 188. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth? A) Cesarean B) Vaginal C) Forceps-assisted D) Vacuum extraction

A Response: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

Chapter 14, 6 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 5 Page: 389 200. The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first? A) Feel for the fetal buttocks or head while palpating the abdomen. B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C) Palpate for the presenting part in the area just above the symphysis pubis. D) Determine flexion by pressing downward toward the symphysis pubis.

A Response: The first maneuver involves feeling for the buttocks and head . Next the nurse palpates on which side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

Chapter 13, 8 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 6 Page: 376 189. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A) Latent phase of the first stage B) Active phase of the first stage C) Transition phase of the first stage D) Perineal phase of the second stage

A Response: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, and contractions occurring every 1 to 2 minutes lasting 60 to 90 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother.

Chapter 17, 4 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 4 Page: 491 4. Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled

A Response: The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

Chapter 16, 15 Format: Multiple Choice Chapter: 16 Client Needs: A-2 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 452 240. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle

A Response: Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.

Chapter 14, 2 Format: Multiple Choice Chapter: 14 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 387 196. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next? A) Check the fetal heart rate. B) Perform a vaginal exam. C) Notify the physician immediately. D) Change the linen saver pad.

A Response: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The physician should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the physician has been notified.

Chapter 13, 5 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Application Difficulty: Difficult Integrated Processes: Nursing Process Objective: 3 Page: 372 186. A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A) Supine B) Lithotomy C) Upright D) Knee-chest

C Response: The use of any upright position helps to reduce the length of labor. Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy. The knee-chest position would assist in rotating the fetus in a posterior position.

Chapter 12, 8 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 320 174. A client's last menstrual period was April 11. Using Nagele's rule, her estimated date of birth (EDB) would be: A) January 4 B) January 18 C) January 25 D) February 24

B Response: To use Nagele's rule, subtract 3 months and then add 7 days to the first day of the client's LMP (April 11): April minus 3 months is January, plus 7 days is 18. Thus, her EDB would be January 18 of the next year.

Chapter 15, 14 Format: Multiple Choice Chapter: 15 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 2 Page: 432 224. Which of the following would lead the nurse to suspect that a postpartum woman is having a problem? A) Elevated white blood cell count B) Acute decrease in hematocrit C) Increased levels of clotting factors D) Pulse rate of 60 beats/minute

B Response: Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.

Chapter 16, 11 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 7 Page: 464 236. Which instructions would the nurse include in discharge teaching for parents of a newborn? A) Introducing solid foods immediately to increase sleep cycle B) Demonstrating comfort measures to quiet a crying infant C) Encouraging daily outings to the shopping mall with the newborn D) Allowing the infant to cry for at least an hour before picking him or her up

B Response: Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and stimulation would be more appropriate.

Chapter 15, 1 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 430 211. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus, expecting it to be: A) Two fingerbreadths above the umbilicus B) At the level of the umbilicus C) Two fingerbreadths below the umbilicus D) Four fingerbreadths below the umbilicus

B Response: During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus.

Chapter 13, 3 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Comprehension Difficulty: Easy Integrated Processes: Nursing Process Objective: 7 Page: 371 184. When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A) Extent of opening to its widest diameter B) Degree of thinning C) Passage of the mucous plug D) Fetal presenting part

B Response: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

Chapter 12, 10 Format: Multiple Choice Chapter: 12 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Processes: Nursing Process Objective: 4 Page: 328 176. A client's maternal serum alpha-fetoprotein (MSAFP) level was unusually elevated at 17 weeks. The nurse suspects which of the following? A) Fetal hypoxia B) Open spinal defects C) Down syndrome D) Maternal hypertension

B Response: Elevated MSAFP levels are associated with open neural tube defects. Fetal hypoxia would be noted with fetal heart rate tracings and via nonstress and contraction stress testing. MSAFP in conjunction with marker screening tests would be more reliable for detecting Down syndrome. Maternal hypertension would be noted via serial blood pressure monitoring.

Chapter 16, 10 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Caring Objective: 4 Page: 451 235. Which practice would be least effective in promoting bonding and attachment? A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth

B Response: Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.

Chapter 14, 8 Format: Multiple Choice Chapter: 14 Client Needs: D-3 Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 393 202. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse understands that which of the following must be present? A) Intact membranes B) Cervical dilation of 2 cm or more C) Floating presenting fetal part D) A neonatologist to insert the electrode

B Response: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

Chapter 15, 7 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Teaching/Learning Objective: 2 Page: 437 217. A postpartum client who is bottle feeding her newborn asks, "When should my period will return?" Which response by the nurse would be most appropriate? A) "It's difficult to say, but it will probably return in about 2 to 3 weeks." B) "It varies, but you can estimate it returning in about 7 to 9 weeks." C) "You won't have to worry about it returning for at least 3 months." D) "You don't have to worry about that now. It'll be quite a while."

B Response: For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.

Chapter 15, 9 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 4 Page: 438 219. Which of the following would the nurse interpret as being least indicative of paternal engrossment? A) Demonstrating pleasure when touching or holding the newborn B) Identifying imperfections in the newborn's appearance C) Being able to distinguish his newborn from others in the nursery D) Showing feelings of pride with the birth of the newborn

B Response: Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

Chapter 16, 5 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 447 230. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A) Presence of lochia serosa B) Frequent scant voidings C) Fundus firm, below umbilicus D) Milk filling in both breasts

B Response: Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

Chapter 17, 6 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 489 6. A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this."

B Response: Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

Chapter 13, 4 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 6 Page: 377 185. A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following? A) Increased energy level with alternating strong and weak contractions B) Moderately strong contractions every 4 minutes, lasting about 1 minute C) Contractions noted in the front of abdomen that stop when she walks D) Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

B Response: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

Chapter 17, 9 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 493 9. Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors

B Response: Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

Chapter 11, 13 Format: Multiple Choice Chapter: 11 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Processes: Nursing Process Objective: 4 Page: 302 164. A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which of the following? A) Excess folic acid, which could increase the risk for neural tube defects B) Mercury, which could harm the developing fetus if eaten in large amounts C) Lactose, which leads to abdominal discomfort, gas, and diarrhea D) Low-quality protein that does not meet the woman's requirements

B Response: Nearly all fish and shellfish contain traces of mercury and some contain higher levels of mercury that may harm the developing fetus if ingested by pregnant women in large amounts. Among these fish are shark, swordfish, king mackerel, and tilefish. Folic acid is found in dark green vegetables, baked beans, black-eyed peas, citrus fruits, peanuts, and liver. Folic acid supplements are needed to prevent neural tube defects. Women who are lactose-intolerant experience abdominal discomfort, gas, and diarrhea if they ingest foods containing lactose. Fish and shellfish are an important part of a healthy diet because they contain high-quality proteins, are low in saturated fat, and contain omega-3 fatty acids.

Chapter 16, 4 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 4 Page: 452 229. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A) "You have your daddy's eyes." B) "He looks like a frog to me." C) "Where did you get all that hair?" D) "He seems to sleep a lot."

B Response: Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

Chapter 15, 15 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 2 Page: 433 225. A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A) "You must have an infection, so let me get a urine specimen." B) "Your body is undergoing many changes that cause your bladder to fill quickly." C) "Your uterus is not contracting as quickly as it should." D) "The anesthesia that you received is wearing off and your bladder is working again."

B Response: Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.

Chapter 11, 5 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 3 Page: 291 156. A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which of the following would the nurse include? A) Ankle edema B) Urinary frequency C) Backache D) Hemorrhoids

B Response: The client is in her first trimester and would most likely experience urinary frequency as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids would be more common during the later stages of pregnancy.

Chapter 15, 12 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 4 Page: 439 222. A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A) Expectations B) Transition to mastery C) Reality D) Taking-in

B Response: The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.

Chapter 13, 11 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Teaching/Learning Objective: 3 Page: 362 192. After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful? A) The bony pelvis plays a lesser role during labor than soft tissue. B) The pelvic outlet is associated with the true pelvis. C) The false pelvis lies below the imaginary linea terminalis. D) The false pelvis is the passageway through which the fetus travels.

B Response: The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

Chapter 13, 9 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 3 Page: 363 190. A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A) Platypelloid B) Gynecoid C) Android D) Anthropoid

B Response: The most favorable pelvic shape for vaginal delivery is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.

Chapter 12, 3 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 6 Page: 347 169. When describing childbirth education to a pregnant woman and her partner, the nurse emphasizes that the primary goal of these classes is to: A) Equip a couple with the knowledge to experience a pain-free childbirth B) Provide knowledge and skills to actively participate in birth C) Eliminate anxiety so that they can have an uncomplicated birth D) Empower the couple to totally control the birth process

B Response: The primary focus of childbirth education is to provide information and support to clients and their families to foster a more active role in the upcoming birth. Some methods of childbirth education focus on pain-free childbirth. Information provided in childbirth education classes helps to minimize anxiety and provide the couple with control over the situation, but elimination of anxiety or total control is unrealistic.

Chapter 17, 3 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 3 Page: 488 3. After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia

B Response: The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

Chapter 16, 7 Format: Multiple Choice Chapter: 16 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 467 232. The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from: A) Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D) Becoming pregnant with an Rh-positive fetus

B Response: The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM) within 72 hours after childbirth to prevent sensitization.

Chapter 12, 5 Format: Multiple Choice Chapter: 12 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 3 Page: 321 171. During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. Which nursing diagnosis would be the priority for this client? A) Ineffective tissue perfusion related to supine hypotensive syndrome B) Impaired gas exchange related to pulmonary congestion C) Activity intolerance related to increased metabolic requirements D) Anxiety related to fear of pregnancy outcome

B Response: Typically, heart rate increases by approximately 10 to 15 beats per minute during pregnancy and the lungs should be clear. Dyspnea may occur during the third trimester as the enlarging uterus presses on the diaphragm. However, the findings described indicate that the woman is experiencing impaired gas exchange. There is no evidence to support supine hypotensive syndrome, increased metabolism, or anxiety.

Chapter 17, 11 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 484 11. The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation

B Response: Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

Chapter 13, 10 Format: Multiple Choice Chapter: 13 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Processes: Nursing Process Objective: 1 Page: 361 191. A woman telephones her health care provider and reports that her waters just broke. Which suggestion by the nurse would be most appropriate? A) "Call us back when you start having contractions." B) "Come to the clinic or emergency department for an evaluation." C) "Drink 3 to 4 glasses of water and lie down." D) "Come in as soon as you feel the urge to push."

B Response: When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

Chapter 12, 15 Format: Multiple Choice Chapter: 12 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Processes: Teaching/Learning Objective: 4 Page: 330 181. Which of the following would the nurse include when teaching a pregnant woman about chorionic villi sampling? A) "The results should be available in about a week." B) "You'll have an ultrasound first and then the test." C) "Afterwards, you can resume your exercise program." D) "This test is very helpful for identifying spinal defects."

B Response: With CVS, an ultrasound is done first to localize the embryo. Results are usually available within 48 hours. After the procedure, the woman should refrain from any strenuous activity for the next 48 hours. CVS can be used to detect numerous genetic disorders but not neural tube defects.

Chapter 14, 13 Format: Multiple Choice Chapter: 14 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 3 Page: 393 207. After describing continuous electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching? A) "This type of monitoring is the most accurate method for our baby." B) "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C) "This type of monitoring can only be used after my membranes rupture." D) "You'll be inserting a special electrode into my baby's scalp."

B Response: With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.

Chapter 11, 7 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Difficult Integrated Processes: Teaching/Learning Objective: 3 Page: 298 158. The nurse is discussing the insulin needs of a primaparous client with diabetes who has been using insulin for the past few years. The nurse informs the client that her insulin needs will increase during pregnancy based on the nurse's understanding that the placenta produces: A) hCG, which increases maternal glucose levels B) hPL, which deceases the effectiveness of insulin C) Estriol, which interferes with insulin crossing the placenta D) Relaxin, which decreases the amount of insulin produced

B Response: hPL acts as an antagonist to insulin, so the mother must produce more insulin to overcome this resistance. If the mother has diabetes, then her insulin need would most likely increase to meet this demand. hCG does not affect insulin and glucose level. Estrogen, not estriol, is believed to oppose insulin. In addition, insulin does not cross the placenta. Relaxin is not associated with insulin resistance.

Chapter 12, 2 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Communication and Documentation Objective: 2 Page: 322 168. On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. The nurse records this finding as: A) Hegar's sign B) Goodell's sign C) Chadwick's sign D) Homans' sign

C Response: Chadwick's sign refers to the bluish coloration of the cervix and vaginal mucosa. Hegar's sign refers to softening of the isthmus. Goodell's sign refers to softening of the cervix. Homans' sign indicates pain on dorsiflexion of the foot.

Chapter 14, 14 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 8 Page: 413 208. When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? A) Every 4 hours B) Every 60 minutes C) Every 30 minutes D) Every 15 minutes

C Response: During the active phase of labor, FHR is monitored every 30 minutes. The woman's temperature is typically assessed every 4 hours during the first stage of labor. Contractions and vital signs are monitored every 30 to 60 minutes during the latent phase; contractions are assessed every 15 minutes during the transition phase.

Chapter 16, 3 Format: Multiple Choice Chapter: 16 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 456 228. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? A) Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D) Bromocriptine (Parlodel)

C Response: A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

Chapter 17, 1 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Comprehension Difficulty: Easy Integrated Processes: Teaching/Learning Objective: 2 Page: 480 1. When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary

C Response: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

Chapter 16, 2 Format: Multiple Choice Chapter: 16 Client Needs: D-1 Cognitive Level: Application Difficulty: Easy Integrated Processes: Nursing Process Objective: 5 Page: 452 227. To decrease the pain associated with an episiotomy immediately after birth, the nurse would: A) Offer warm blankets B) Encourage the woman to void C) Apply an ice pack to the site D) Offer a warm sitz bath

C Response: An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

Chapter 11, 3 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 291 154. A gravida 2 para 1 client in the 10th week of her pregnancy says to the nurse, "I've never urinated as often as I have for the past three weeks." Which response would be most appropriate for the nurse to make? A) "Having to urinate so often is annoying. I suggest that you watch how much fluid you are drinking and limit it." B) "You shouldn't be urinating this frequently now; it usually stops by the time you're eight weeks pregnant. Is there anything else bothering you?" C) "By the time you are 12 weeks pregnant, this frequent urination should no longer be a problem, but it is likely to return toward the end of your pregnancy." D) "Women having their second child generally don't have frequent urination. Are you experiencing any burning sensations?"

C Response: As the uterus grows, it presses on the urinary bladder, causing the increased frequency of urination during the first trimester. This complaint lessens during the second trimester only to reappear in the third trimester as the fetus begins to descend into the pelvis, causing pressure on the bladder.

Chapter 12, 6 Format: Multiple Choice Chapter: 12 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 4 Page: 329 172. When preparing a woman for an amniocentesis, the nurse would instruct her to do which of the following ? A) Shower with an antiseptic scrub. B) Swallow the pre-procedure sedative. C) Empty her bladder. D) Lie on her left side.

C Response: Before an amniocentesis, the woman should empty her bladder to reduce the risk of bladder puncture during the procedure. Showering with an antiseptic scrub and pre-procedural sedation are not necessary. The woman usually is positioned in a way that provides an adequate pocket of amniotic fluid on ultrasound.

Chapter 11, 1 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Communication and Documentation Objective: 1 Page: 290 152. During a vaginal exam, the nurse notes that the cervix has a bluish color. The nurse documents this finding as: A) Hegar's sign B) Goodell's sign C) Chadwick's sign D) Ortolani's sign

C Response: Bluish coloration of the cervix is termed Chadwick's sign. Hegar's sign refers to the softening of the lower uterine segment or isthmus. Goodell's sign refers to the softening of the cervix. Ortolani's sign is a maneuver done to identify developmental dysplasia of the hip in infants.

Chapter 13, 1 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 362 182. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A) "I'm feeling contractions mostly in my back." B) "My contractions are about 6 minutes apart and regular." C) "The contractions slow down when I walk around." D) "If I try to talk to my partner during a contraction, I can't."

C Response: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

Chapter 14, 9 Format: Multiple Choice Chapter: 14 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 4 Page: 394 203. When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next? A) Have the woman change her position. B) Administer oxygen. C) Notify the health care provider. D) Continue to monitor the pattern every 15 minutes.

C Response: Fetal tachycardia as evidenced by a fetal heart rate greater than 160 bpm accompanied by a decrease in variability and late decelerations is an ominous sign indicating the need for prompt intervention. The health care provider should be notified immediately and then measures should be instituted such as having the woman lie on her side and administering oxygen. In this instance, monitoring should be continuous to detect any further changes and evaluate the effectiveness of interventions.

Chapter 16, 6 Format: Multiple Choice Chapter: 16 Client Needs: D-1 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 5 Page: 464 231. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort? A) "Express some milk from your breasts every so often to relieve the distention." B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C) "Apply ice packs to your breasts to reduce the amount of milk being produced." D) "Take several warm showers daily to stimulate the milk let-down reflex."

C Response: For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

Chapter 16, 14 Format: Multiple Choice Chapter: 16 Client Needs: D-1 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 456 239. A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding? A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on

C Response: Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.

Chapter 11, 10 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Application Difficulty: Difficult Integrated Processes: Nursing Process Objective: 5 Page: 308 161. The nurse is assessing a pregnant woman in the second trimester. Which of the following tasks would indicate to the nurse that the client is incorporating the maternal role into her personality? A) The woman demonstrates concern for herself and her fetus as a unit. B) The client identifies what she must give up to assume her new role. C) The woman acknowledges the fetus as a separate entity within her. D) The client demonstrates unconditional acceptance without rejection.

C Response: Incorporation of the maternal role into her personality indicates acceptance by the pregnant woman. In doing so, the woman becomes able to identify the fetus as a separate individual. Demonstrating concern for herself and her fetus as a unit is associated with introversion and more commonly occurs during the third trimester. Identification of what the mother must give up to assume the new role occurs during the first trimester. Demonstrating unconditional acceptance without rejection occurs during the third trimester.

Chapter 15, 11 Format: Multiple Choice Chapter: 15 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 2 Page: 431 221. The nurse teaches a postpartum client how to do Kegel exercises for which reason? A) Reduce lochia B) Promote uterine involution C) Improve pelvic floor tone D) Alleviate perineal pain

C Response: Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

Chapter 14, 1 Format: Multiple Choice Chapter: 14 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 6 Page: 404 195. A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A) Butorphanol B) Fentanyl C) Naloxone D) Promethazine

C Response: Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.

Chapter 16, 8 Format: Multiple Choice Chapter: 16 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 445 233. Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor

C Response: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

Chapter 15, 6 Format: Multiple Choice Chapter: 15 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Processes: Nursing Process Objective: 2 Page: 432 216. When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) Deep red, fleshy-smelling lochia B) Voiding of 350 cc C) Heart rate of 120 beats/minute D) Profuse sweating

C Response: Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.

Chapter 12, 12 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 5 Page: 340 178. A pregnant woman in the 36th week of gestation complains that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which of these interventions is appropriate for the nurse to suggest? A) "Limit your intake of fluids." B) "Eliminate salt from your diet." C) "Try elevating your legs when you sit." D) "Wear spandex-type full-length pants."

C Response: The client is experiencing dependent edema due to the effect of gravity and increased capillary permeability caused by elevated hormone levels and increased blood volume, and accompanied by sodium and water retention. The best suggestion would be to encourage the woman to elevate her legs when sitting to promote venous return and minimize the effects of gravity. Neither fluids nor salt should be limited or eliminated. Six to eight glasses of water each day are necessary to replace fluids lost through perspiration. Foods high in sodium should be avoided. Spandex-type full-length pants would be constricting and interfere with venous return.

Chapter 16, 9 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 1 Page: 450 234. When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth, which is termed: A) Reciprocity B) Engrossment C) Bonding D) Attachment

C Response: The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

Chapter 14, 5 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Communication and Documentation Objective: 7 Page: 387 199. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A) +2 station B) 0 station C) -2 station D) Crowning

C Response: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

Chapter 16, 13 Format: Multiple Choice Chapter: 16 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 7 Page: 464 238. Which method would be most effective in evaluating the parents' understanding about their newborn's care? A) Demonstrate all infant care procedures B) Allow the parents to state the steps of the care C) Observe the parents performing the procedures D) Routinely assess the newborn for cleanliness

C Response: The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental roles develop and grow through interaction with their newborn. The nurse would involve both parents in the newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for cleanliness would provide little information about parental learning.

Chapter 13, 6 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 7 Page: 378 187. A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A) Latent phase of the first stage of labor B) Active phase of the first stage of labor C) Transition phase of the first stage of labor D) Pelvic phase of the second stage of labor

C Response: The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The active phase is characterized by moderate to strong contractions every 2 to 5 minutes, cervical dilation of 4 to 7 cm and effacement of 40% to 80%, with the mother becoming intense and inwardly focused. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.

Chapter 14, 12 Format: Multiple Choice Chapter: 14 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 393 206. When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR? A) Over the uterine fundus where contractions are most intense B) Above the umbilicus toward the right side of the diaphragm C) Between the umbilicus and the symphysis pubis D) Between the xiphoid process and umbilicus

C Response: The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

Chapter 12, 7 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Application Difficulty: Difficult Integrated Processes: Communication and Documentation Objective: 2 Page: 321 173. A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as: A) 3 2 1 0 3 B) 3 1 2 2 3 C) 4 1 1 1 3 D) 4 2 1 3 1

C Response: Using the GTPAL method, the woman's history would be documented as 4 (her fourth pregnancy), 1 (number of term pregnancies), 1 (number of pregnancies ending in preterm birth), 1 (number of pregnancies ending before 20 weeks or viability), and 3 (number of living children).

Chapter 12, 14 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 5 Page: 346 180. A pregnant woman is flying across the country to visit her family. After teaching the woman about traveling during pregnancy, which statement indicates that the teaching was successful? A) "I'll sit in a window seat so I can focus on the sky to help relax me." B) "I won't drink too much fluid so I don't have to urinate so often." C) "I'll get up and walk around the airplane about every 2 hours." D) "I'll do some upper arm stretches while sitting in my seat."

C Response: When traveling by airplane, the woman should get up and walk about the plane every 2 hours to promote circulation. An aisle seat is recommended so that she can have easy access to the aisle. Drinking water throughout the flight is encouraged to maintain hydration. Calf-tensing exercises are important to improve circulation to the lower extremities.

Chapter 11, 14 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Difficult Integrated Processes: Teaching/Learning Objective: 3 Page: 295 165. Which of the following changes in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy? A) Ligament tightening B) Decreased swayback C) Increased lordosis D) Joint contraction

C Response: With pregnancy, the woman's center of gravity shifts forward, requiring a realignment of the spinal curvatures. There is an increase in the normal lumbosacral curve (lordosis). Ligaments of the sacroiliac joints and pubis symphysis soften and stretch. Increased swayback and an upper spine extension to compensate for the enlarging abdomen occur. Joint relaxation and increased mobility occur due to the influence of the hormones relaxin and progesterone.

Chapter 15, 2 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Comprehension Difficulty: Easy Integrated Processes: Nursing Process Objective: 2 Page: 431 212. When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A) Greater than after a vaginal delivery B) About the same as after a vaginal delivery C) Less than after a vaginal delivery D) Saturated with clots and mucus

C Response: Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

Chapter 11, 12 Format: Multiple Choice Chapter: 11 Client Needs: D-1 Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Analysis Objective: 4 Page: 304 163. The nurse is teaching a pregnant woman with a prepregnancy body mass index of 26 about recommended weight gain. The nurse determines that the teaching was successful when the woman states that she should gain no more than which amount during pregnancy? A) 35 to 40 pounds B) 25 to 35 pounds C) 28 to 40 pounds D) 15 to 25 pounds

D Response: A woman with a body mass index of 26 is considered overweight and should gain no more than 15 to 25 pounds during pregnancy. Women with a body mass index of 18 5 to 24.9 (considered healthy weight) should gain 25 to 35 pounds. A woman with a body mass index less than 18.5 should gain 28 to 40 pounds.

Chapter 14, 7 Format: Multiple Choice Chapter: 14 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 2 Page: 387 201. A client states, "I think my waters broke! I felt this gush of fluid between my legs." The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns: A) Yellow B) Olive green C) Pink D) Blue

D Response: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine paper that remains yellow to olive green suggests that the membranes are most likely intact.

Chapter 12, 9 Format: Multiple Choice Chapter: 12 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Nursing Process Objective: 4 Page: 332 175. During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. The nurse interprets this as: A) Variable decelerations B) Fetal tachycardia C) A nonreactive pattern D) Reactive pattern

D Response: A reactive nonstress test indicates fetal activity, as evidenced by acceleration of the fetal heart rate by at least 15 bpm for at least 15 seconds within a 20-minute recording period. If this does not occur, the test is considered nonreactive. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm.

Chapter 11, 6 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Processes: Nursing Process Objective: 3 Page: 294 157. A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating which of the following? A) Iron-deficiency anemia B) A multiple gestation pregnancy C) Greater-than-expected weight gain D) Hemodilution of pregnancy

D Response: During pregnancy, the red blood cell count increases along with an increase in plasma volume. However, there is a greater increase in the plasma volume as a result of hormonal factors and sodium and water retention. Thus, the plasma increase exceeds the increase in RBCs, resulting in hemodilution of pregnancy, which is also called physiologic anemia of pregnancy. Changes in maternal iron levels would be more indicative of an iron-deficiency anemia. Although anemia may be present with a multiple gestation, an ultrasound would be a more reliable method of identifying it. Weight gain does not correlate with hemoglobin levels.

Chapter 12, 11 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 340 177. When assessing a pregnant woman in her last trimester, which question would be most appropriate to use to gather information about weight gain and fluid retention? A) "What's your usual dietary intake for a typical day?" B) "What size maternity clothes are you wearing now?" C) "How puffy does your face look by the end of a day?" D) "How swollen do your ankles appear before you go to bed?

D Response: Edema, especially in the dependent areas such as the legs and feet, occurs throughout the day due to gravity. It improves after a night's sleep. Therefore, questioning the client about ankle swelling would provide the most valuable information. Asking about her usual dietary intake would be valuable in assessing complaints of heartburn and indigestion. The size of maternity clothing may provide information about weight gain but would have little significance for fluid retention. Swelling in the face may suggest preeclampsia, especially if it is accompanied by dizziness, blurred vision, headaches, upper quadrant pain, or nausea.

Chapter 12, 13 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Nursing Process Objective: 5 Page: 346 179. A pregnant woman needs an update in her immunizations. Which of the following vaccinations would the nurse ensure that the woman receives? A) Measles B) Mumps C) Rubella D) Hepatitis B

D Response: Hepatitis B vaccine should be considered during pregnancy. Immunizations for measles, mumps, and rubella are contraindicated during pregnancy.

Chapter 14, 10 Format: Multiple Choice Chapter: 14 Client Needs: D-1 Cognitive Level: Analysis Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 6 Page: 399 204. A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A) "The warmth and buoyancy of the water has a nice relaxing effect." B) "I can stay in the bath for as long as I feel comfortable." C) "My cervix should be dilated more than 5 cm before I try using this method." D) "The temperature of the water should be at least 105 degrees F."

D Response: Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105 degrees would be too warm. The warmth and buoyancy have a relaxing effect and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.

Chapter 15, 3 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 2 Page: 436 213. The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A) Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D) Instructing her to apply ice packs to both breasts every other hour

D Response: If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.

Chapter 11, 2 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 3 Page: 292 153. The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time? A) Dysuria B) Dyspnea C) Constipation D) Urinary frequency

D Response: Lightening refers to the descent of the fetal head into the pelvis and engagement. With this descent, pressure on the diaphragm decreases, easing breathing, but pressure on the bladder increases, leading to urinary frequency. Dysuria might indicate a urinary tract infection. Constipation may occur throughout pregnancy due to decreased peristalsis, but it is unrelated to lightening.

Chapter 17, 5 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 484 5. The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production

D Response: Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

Chapter 12, 4 Format: Multiple Choice Chapter: 12 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Nursing Process Objective: 3 Page: 324 170. When assessing a woman at follow-up prenatal visits, the nurse would anticipate which of the following to be performed? A) Hemoglobin and hematocrit B) Urine for culture C) Fetal ultrasound D) Fundal height measurement

D Response: On every follow-up visit, fundal height measurements are performed to evaluate fetal growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be done on the initial visit and then repeated if the woman's status indicates a need for doing so. Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal period, but it is not done at every visit.

Chapter 17, 2 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Comprehension Difficulty: Difficult Integrated Processes: Nursing Process Objective: 2 Page: 489 2. A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds based on the understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter

D Response: The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

Chapter 15, 10 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Comprehension Difficulty: Easy Integrated Processes: Nursing Process Objective: 2 Page: 431 220. A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like

D Response: The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

Chapter 11, 8 Format: Multiple Choice Chapter: 11 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 3 Page: 298 159. When teaching a pregnant client about the physiologic changes of pregnancy, the nurse reviews the effect of pregnancy on glucose metabolism. Which of the following would the nurse include as the underlying reason for the effect? A) Pancreatic function is affected by pregnancy. B) Glucose is utilized more rapidly during a pregnancy. C) The pregnant woman increases her dietary intake. D) Glucose moves through the placenta to assist the fetus.

D Response: The growing fetus has large needs for glucose, amino acids, and lipids, placing demands on maternal glucose stores. During the first half of pregnancy, much of the maternal glucose is diverted to the growing fetus. The pancreas continues to function during pregnancy. However, the placental hormones can affect maternal insulin levels. The demand for glucose by the fetus during pregnancy is high, but it is not necessarily used more rapidly. Placental hormones, not the woman's dietary intake, play a major role in glucose metabolism during pregnancy.

Chapter 15, 5 Format: Multiple Choice Chapter: 15 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 2 Page: 431 215. A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A) "Your uterus is still shrinking in size; that's why you're feeling this pain." B) "Let me check your vaginal discharge just to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a tough workout." D) "The baby's sucking releases a hormone that causes the uterus to contract."

D Response: The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

Chapter 17, 10 Format: Multiple Choice Chapter: 17 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Processes: Teaching/Learning Objective: 2 Page: 492 10. When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A) Hearing B) Touch C) Taste D) Vision

D Response: Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

Chapter 13, 12 Format: Multiple Choice Chapter: 13 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Processes: Communication and Documentation Objective: 3 Page: 368 193. A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as: A) +4 B) +2 C) 0 D) -2

D Response: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.