NCLEX-Style Review Questions Women's
A woman who has had repeated candidal infections asks the nurse about ways to help prevent them. Which response(s) by the nurse would be appropriate? Select all that apply. "Avoid wearing exercise pants with spandex." "Wash your underwear in cold water." "Use white, unscented toilet paper." "Wash your genital area with antibacterial soap frequently." "Shower instead of taking baths."
"Avoid wearing exercise pants with spandex.", "Use white, unscented toilet paper.", "Shower instead of taking baths." Rationale:Preventive measures for women with frequent vulvovaginal infections include: washing underwear in hot water; showering instead of taking tub baths; washing the genital with a mild unscented soap; using white, unscented toilet paper; and avoiding tight pants and exercise clothes that contain spandex.
A client is diagnosed with bacterial vaginosis and is prescribed medication therapy. The nurse would anticipate which drugs as being prescribed? Select all that apply. penicillin G metronidazole doxycycline azithromycin clindamycin
- metronidazole, - clindamycin Rationale:Clindamycin or metronidazole is used to treat bacterial vaginosis. Penicillin G may be used to treat syphilis. Doxycycline or azithromycin is used to treat chlamydia.
In preparing a talk about sexually transmitted infections (STIs) of chlamydia and gonorrhea for high school students, the nurse should emphasize which group as being at high risk? Select all that apply. persons with a lack of personal hygiene women who are single individuals with multiple sex partners women under the age of 25 years persons using consistent barrier protection
- women who are single - individuals with multiple sex partners - women under the age of 25 years Rationale:High-risk groups include single women, women younger than 25 years, black women, women with a history of STIs, those with new or multiple sex partners, those with inconsistent use of barrier contraception, and women living in communities with high infection rates. Lack of personal hygiene is not considered a risk factor for STIs.
The nurse is providing care to a client with abnormal uterine bleeding. Treatment with medications has been unsuccessful, and surgical intervention is being considered. The nurse identifies which technique as being the last resort? Correct Response: hysterectomy
Rationale: If the client does not respond to medical therapy, surgical intervention might include dilation and curettage (D&C;), endometrial ablation, uterine artery embolization, or hysterectomy. Of these, hysterectomy is considered a last resort.
A nurse is preparing a presentation for a local community women's group about menopause. When describing the body system changes that occur, the nurse would include which changes? Select all that apply. Correct Response: - increased abdominal fat, - vaginal dryness - hot flashes - decreased bone density
Rationale: Menopause may be associated with hot flashes, increased abdominal fat, vaginal dryness, decreased bone density, dry, thinning skin, and increased waist size.
Working at the college health care clinic, the nurse recognizes the importance of educating students that the human papillomavirus has been confirmed to be the cause of essentially all cases of which type of cancer? ovarian vaginal cervical uterine
cervical Rationale:Prophylactic HPV vaccines are designed primarily for cervical cancer prevention. It plays no role in the prevention of ovarian, uterine, or vaginal cancers.
A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted." "There is some type of blood incompatibility between you and your baby that's causing the problem." "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." "We really don't know why jaundice develops in some babies and not in others. We just know how to treat it."
"Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." Rationale:The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice associated with a blood incompatibility. Impaired bilirubin excretion, such as from an obstruction in the biliary tree, also can lead to jaundice. The causes of newborn jaundice are known; jaundice usually results from one of these three mechanisms.
A woman who is HIV positive and receiving drug therapy comes to the clinic and says, "I have no appetite, and then when I do eat, I get sick to my stomach." Which suggestion would be least effective? "Try some high-protein drinks or foods." "Drink fluids with anything that you eat." "Try eating small meals spaced throughout the day." "Eat some dry crackers when you feel nauseated."
"Drink fluids with anything that you eat." Rationale:Food and fluid intake should be separated to prevent overfilling. High-protein drinks and foods will provide quick and easy protein and calories. Dry crackers are helpful in alleviating nausea. Eating smaller meals spaced evenly throughout the day will prevent the client from feeling overfilled and bloated.
A woman opts to use a diaphragm for contraception. Which instruction would be most important for the nurse to provide? "Keep the diaphragm in place for no more than 4 hours after intercourse." "Wet the diaphragm with water first before inserting it." "Replace the diaphragm every 6 months." "Have your diaphragm refitted if you lose 10 pounds (4.5 kilograms) or more?"
"Have your diaphragm refitted if you lose 10 pounds (4.5 kilograms) or more." Rationale:Diaphragms should be refitted after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds (4.5 kilograms) or more. A diaphragm usually is replaced every 1 to 2 years. A diaphragm should remain in place for at least 6 hours after intercourse. A contraceptive sponge, not a diaphragm, should be wetted with water before insertion.
The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? "He needs to get food orally to make vitamin K." "The newborn's gut is sterile at birth." "His stomach can hold approximately 10 ounces." "The muscle opening that leads into the stomach is not mature."
"His stomach can hold approximately 10 ounces." Rationale:A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.
The parents of a 2-day-old newborn are getting ready to go home with their baby. The mother is breastfeeding the newborn. In preparation for discharge, the nurse obtains the newborn's weight. The newborn weighs 7 lb (3180 g) this morning. The parents voice concern, saying, "Our newborn lost weight since being born. Our newborn was 7 lb 8 oz (3404 g) and now our newborn is less. What is going on?" Which response by the nurse would be most appropriate? "Looks like there might be a problem with your breast milk. Let's try formula and see what happens." "This is an interesting change. Let me talk to your health care provider about the weight loss." "This weight loss is from not eating enough. You will need to breastfeed your newborn more often." "I understand your concern. It is normal for this to happen but your newborn will gain it back quickly."
"I understand your concern. It is normal for this to happen but your newborn will gain it back quickly." Rationale:Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life. The weight loss is a normal finding. There is no need to talk to the health care provider, increase the number of breastfeeding sessions, or switch to formula.
During a routine health visit for an 11-year-old girl, her mother asks the nurse, "My daughter just got her period about 4 months ago, but they haven't been very regular so far. How long might it take until she gets regular?" Which response by the nurse would be most appropriate? "That's odd. Her periods should be getting regular by now." "She should start getting regular after about 2 to 3 more months." "It can take up to 2 years once she starts for the periods to become regular." "If her periods are not regular now, odds are they will be irregular from now on."
"It can take up to 2 years once she starts for the periods to become regular." Rationale:Once menarche has occurred, cycles may take up to 2 years to become regular, ovulatory cycles. Telling the mother that her daughter's periods would get regular in 2 to 3 months or that she should be having regular periods by now is incorrect. Also, telling the mother that her daughter's periods will continue to be irregular is untrue and inappropriate.
A nurse is assessing the congenital reflexes of a newborn. The newborn's parent is watching the nurse and asks, "Why are you testing these things?" Which response by the nurse would be appropriate? "It is the way we check your newborn's muscle strength." "It is a way for us to check your newborn's brain and nerve function." "It tells us if there are any problems with the joints." "It lets us know if your newborn will need special exercises."
"It is a way for us to check your newborn's brain and nerve function." Rationale:The presence and strength of a reflex is an important indication of neurologic development and function. A reflex is an involuntary muscular response to a sensory stimulus. It is built into the nervous system and does not need the intervention of conscious thought to take effect. Reflex testing does not provide information about muscle strength, joints, or the need for exercises.
After teaching a group of college-aged students about condom use, the nurse determines that additional teaching is needed when the students make which statement? "Condoms should be stored in a cool, dry place." "It's okay to use petroleum jelly with a latex condom." "Latex condoms are the best protection from STIs." "Condoms should be applied before any genital contact."
"It's okay to use petroleum jelly with a latex condom." Rationale:If external lubricants are used, use only water-based lubricants with latex condoms. Oil-based or petroleum-based lubricants, such as body lotion, massage oil, or cooking oil, can weaken latex condoms. Latex condoms are the best protection from STIs. Condoms are applied before any genital contact because sperm is present in preejactulate fluid. Condoms also should be stored in a cool, dry place away from direct sunlight to prevent deterioration.
A young adult woman comes to the clinic for an evaluation. During the visit, the woman tells the nurse that she suffers from painful cramps during her menses. She states, "It is worse the first couple of days and then it gets better. I take ibuprofen and it helps. Is there anything else I can do?" Which information would the nurse incorporate into the response? Select all that apply. "Limit the amount of salty foods you eat." "Take warm showers to help relax." "Use cool compresses to your lower belly." "Try to exercise." "Keep your intake of water low
"Limit the amount of salty foods you eat." Take warm showers to help relax.", "Try to exercise." Rationale:Tips for managing dysmenorrhea include: exercising to increase endorphins and suppress prostaglandin release; limiting salty foods to prevent fluid retention; increasing water consumption to serve as a natural diuretic; using heating pads or warm baths to increase comfort; and taking warm showers to promote relaxation.
After a discussion on the human papillomavirus (HPV) vaccine with a parent and 15-year-old adolescent at a well-child visit, the nurse recognizes the discussion was successful when the parent makes which statement? "My adolescent will need three injections over a 6-month period." "My adolescent will need to get a total of two injections in the next 3 months." "One injection will give my adolescent a lifetime of protection." "My adolescent will need one injection every 5 years."
"My adolescent will need three injections over a 6-month period." Rationale: For a client 15 through 45 years of age, the HPV vaccine is given using a 3-dose schedule; the second shot should be given 2 months after the first shot and the third shot should be given 6 months after the first shot. If the client was 9 through 14 years of age, the HPV vaccine can be given using a 2-dose or 3-dose schedule. For the 2-dose schedule, the second shot should be given 6 to 12 months after the first shot. If the second shot is given less than 5 months after the first shot, a third shot should be given at least 4 months after the second shot. For the 3-dose schedule, the second shot should be given 2 months after the first shot and the third shot should be given 6 months after the first shot.
A couple is deciding about contraceptive measures. The male partner has decided to undergo a vasectomy. After teaching the client about this procedure, which client statement indicates the need for additional teaching? "I will be able to go back to work in a day or two." "Right after surgery, my semen will be sperm-free." "I will be awake and will get local anesthesia." "I will have this done in my urologist's office."
"Right after surgery, my semen will be sperm-free." Rationale:After vasectomy, semen no longer contains sperm. However, this is not immediate. The man must submit semen specimens for analysis 8 to 16 weeks after a vasectomy until two specimens show that no sperm is present. When the specimen shows azoospermia, the man's sterility is confirmed. A vasectomy is usually performed under local anesthesia in a urologist's office, and most men can return to work and normal activities in a day or two.
A woman with candidiasis is prescribed fluconazole. When teaching the woman about this medication, which instruction would the nurse include? "Take 1 dose of the drug by mouth." "Apply the cream to the area for 3 days." "Insert the suppository into the vagina daily for 1 week." "Use the applicator to insert the vaginal tablet."
"Take 1 dose of the drug by mouth." Rationale:Fluconazole, when prescribed, is a 150-mg oral tablet taken as a single dose. Miconazole, clotrimazole, and terconazole are used intravaginally in the form of a cream, tablet, or suppositories for 3 to 7 days.
A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply. "Have her lie on your lap on her back." "Try shushing her loudly." "Try swaddling her nice and snuggly." "Encourage her to suck." "Gently tap her shoulders and back."
"Try shushing her loudly.", "Try swaddling her nice and snuggly.", "Encourage her to suck." Rationale:Recent research outlines five things (the five "S") that parents can do to calm a fussy infant: swaddling tightly; using the side/stomach position on the lap of the caretaker; shushing loudly or continuous white noise; swinging using any rhythmic movement; and sucking (Karp, 2014).
New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll lightly rub his back as we talk to him softly." "We'll hold off on feeding him for a while because he might be too full." "We'll turn the mobile on that's hanging above his head in his crib." "We'll swaddle him snuggly to make him feel secure."
"We'll hold off on feeding him for a while because he might be too full." Rationale:The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.
A nurse is teaching a couple who has chosen condoms as their means of contraception. The nurse determines that the teaching was successful when the couple makes which statements? Select all that apply. "The condom should fit tightly from the tip to the end." "We should remove the condom after intercourse once the penis is no longer erect." "We'll keep the condom in its wrapper until we're ready to use it." "The penis needs to be erect before putting on the condom." "We will use a new condom each time we have sexual intercourse."
"We'll keep the condom in its wrapper until we're ready to use it.", "The penis needs to be erect before putting on the condom.", "We will use a new condom each time we have sexual intercourse." Rationale:A new condom should be used for each sexual intercourse act. It should be kept in its wrapper until it is ready to use, applied to an erect penis and removed while the penis is still erect. There should be about 1/2 inch of empty space at the end to collect ejaculate.
A woman comes to the local women's health clinic for an evaluation. The woman is diagnosed with chlamydia. Which action(s) by the nurse would be important? Select all that apply. Explain that there is no cure for the infection. Instruct the client to avoid alcohol with treatment. Report the condition to public health authorities. Teach the woman how to use the intravaginal medication. Discuss the need for treatment for gonorrhea as well.
- Report the condition to public health authorities - Discuss the need for treatment for gonorrhea as well. Rationale:Federal law in the United States and Canada recognize chlamydia, gonorrhea, and syphilis as notifiable conditions. This means that federal law mandates health care providers to report new cases of these infections to public health authorities. Chlamydia is treated with antibiotics. Because of the common coinfection of chlamydia and gonorrhea, a combination antibiotic regimen is prescribed frequently. Intravaginal medications are used to treat candidal infections. Alcohol should be avoided during treatment for trichomoniasis. Chlamydia can be cured; however, genital herpes cannot be cured.
The client is single, admits to not using condoms during sexual intercourse, and has had multiple partners over the past year. Which symptoms would alert the nurse to a possible gonorrheal infection? Select all that apply. abnormal vaginal discharge nonpalpable lymph nodes abnormal uterine bleeding mild sore throat dysuria
- abnormal vaginal discharge - abnormal uterine bleeding - mild sore throat - dysuria Rationale:Assessment findings for gonorrhea may include: abnormal vaginal discharge, dysuria, abnormal vaginal bleeding, enlarged lymph nodes locally, PID, mild sore throat (for pharyngeal gonorrhea), and rectal infection (itching, soreness, bleeding, discharge).
A 16-year-old girl is brought to the clinic by her mother because she has not had a menstrual period for the past 8 months. Which findings might alert the nurse to the possibility that anorexia nervosa may be contributing to the client's amenorrhea? Select all that apply. bradycardia evidence of secondary sex characteristics hypotension hyperthermia reduced subcutaneous fat
- bradycardia, - hypotension - educed subcutaneous fat Rationale: Hypothermia, bradycardia, hypotension, and reduced subcutaneous fat may be observed in women with amenorrhea with anorexia nervosa as the contributing factor. Evidence of secondary sex characteristics would be a normal finding for a girl of this age.
A nurse is assessing a client and suspects that the client may be experiencing premenstrual dysphoric disorder (PMDD). Applying the American Psychiatric Association criteria, the nurse would assess which symptoms? Select all that apply. focused thinking dysuria sleep difficulties affective lability diarrhea
- sleep difficulties - affective lability - diarrhea Rationale:According to the American Psychiatric Association, a woman must have at least five of the typical symptoms to be diagnosed with PMDD. These must occur during the week before and a few days after the onset of menstruation and must include one or more of the first four symptoms: affective liability; anxiety and tension; persistent or marked anger or irritability; depressed mood, feelings of hopelessness; difficulty concentrating; sleep difficulties; increased or decreased appetite; increased or decreased sexual desire; chronic fatigue; headache; constipation or diarrhea; or breast tenderness and swelling.
Arrange the answers into the correct order. Mouse users arrange by clicking and dragging each answer to the desired location. Keyboard users can arrange though drop down by selecting the right order. A nurse is developing a plan of care for a newborn to minimize the risk for heat loss. The nurse prioritizes potential interventions based on which mechanism is responsible. Place the interventions listed below in the order the nurse would address them based on the mechanism accounting for the greatest to least amount of heat loss. Use all options. 1) Placing the newborn under a radiant warmer during a procedure 2) Using a warmed isolette to transfer a newborn to the nursery 3) Drying the newborn after giving the newborn a bath 4) Encouraging skin-to-skin contact with the mother
1) Placing the newborn under a radiant warmer during a procedure 2) Using a warmed isolette to transfer a newborn to the nursery 3) Drying the newborn after giving the newborn a bath 4) Encouraging skin-to-skin contact with the mother Rationale:The transfer of heat depends on the temperature of the environment, air speed, and water vapor pressure or humidity. Heat exchange between the environment and the newborn involves the same mechanisms as those with any physical object and its environment. Heat can be lost by four mechanisms: radiation which accounts for approximately 39% of heat loss, convection which accounts for about 34% of heat loss, evaporation which accounts for about 24% of heat loss, and conduction which accounts for about 3% of heat loss. Based on the mechanism, the nurse would prioritize placing a newborn under a radiant warmer, using a warmed isolette to transfer the newborn, drying after bathing, and encouraging skin-to-skin contact.
New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age? 10% 14% 16% 12%
10% Rationale:Newborns typically lose approximately 10% of their initial birth weight by 3 to 4 days of age secondary to the loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life.
A woman has opted to use medroxyprogesterone injections for birth control. The client receives the first injection today. The nurse instructs the woman to return to the clinic in how many months for the next injection? 3 2 1 4
3 Rationale:The medroxyprogesterone injection is given intramuscularly every 3 months.
A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal? 38.0° C (100.4° F) 36.0° C (96.8° F) 37.0° C (98.6° F) 35.0° C (95.0° F)
37.0° C (98.6° F) Rationale:On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F).
A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually occurs within the first: 2 to 4 hours of life. 4 to 6 hours of life. 6 to 10 hours of life. 8 to 12 hours of life.
6 to 10 hours of life. Rationale:The infant must make many changes to survive outside the uterus. Immediately after birth, respiratory gas exchange, along with circulatory modifications must occur. During this time, the infant also experiences complex changes in major organ systems. The transition usually takes place within the first 6 to 10 hours of life; however, some adaptations take weeks to attain full maturity.
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 4 to 6 6 to 8 8 to 10 2 to 4
6 to 8 Rationale:From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.
A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 8 5 7 6
7 Rationale:The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).
A nurse is reading a journal article about chlamydia. The nurse would expect to find that what percentage of women are asymptomatic when infected with chlamydia? 30% 90% 70% 50%
70% Rationale:Asymptomatic infection is common among both men and women, affecting 50% and 70%, respectively.
The client has heard of extended-cycle oral contraceptive regimens and desires more information. The nurse explains that these regimens consist of active combination pills, followed by placebo pills. How many days of active combination pills and placebo pills are contained in these regimens? 56 active; 5 placebo 84 active; 7 placebo 42 active; 4 placebo 70 active; 6 placebo
84 active; 7 placebo Rationale:Research has confirmed that the extended use of active OC pills carries the same safety profile as the conventional 28-day regimens. The extended-cycle regimen consists of 84 consecutive days of active combination pills, followed by 7 days of placebo. The woman has four withdrawal-bleeding episodes a year.
During a routine examination, the nurse suspects a teenager is having unprotected sex. To encourage discussion, which action by the nurse would be best? Lecture the teen on the dangers of unprotected sex. Alert the parents to the possibility. Report the teen to Child Protective Services. Be nonjudgmentally direct in the conversation.
Be nonjudgmentally direct in the conversation. Rationale:Health care providers have a unique opportunity to provide counseling and education to their clients. Adolescents are less willing to be open to nurses and less likely to return for care if they are uncertain about confidentiality. Nurses working with adolescents need to convey their willingness to discuss sexual habits, and any interactions with clients need to be direct and nonjudgmental. There is no need to alert the parents or report the teen. Lecturing would be detrimental to the relationship.
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? Hematocrit is 38. Bilirubin level went from 15 to 11. Reticulocyte count is 6%. Skin looks less jaundiced.
Bilirubin level went from 15 to 11. Rationale:The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information.
A mother presents to the clinic with her 15-year-old daughter who is reporting amenorrhea. The girl's menarche was at age 12. When conducting the health history and physical exam, which findings might the nurse identify as suggesting the underlying cause? Select all that apply. hypothyroidism pregnancy lack of exercise emotional distress extreme rapid weight gain
Correct Response: - hypothyroidism - pregnancy - emotional distress - extreme rapid weight gain Rationale:The girl is experiencing secondary amenorrhea. Risk factors include: recent rapid weight gain or loss, pregnancy, vigorous exercise, hypo- or hyperthyroidism, and chronic prolonged emotional stress.
The public health nurse is teaching a community class of couples on fertility awareness-based methods. The nurse determines that additional teaching is needed when one of the couples states that they will be using which method? symptothermal method cervical mucus ovulation method basal body temperature method coitus interruptus method
Correct Response: coitus interruptus method Rationale:Fertility awareness refers to any natural contraceptive method that does not require hormones, pharmaceutical compounds, physical barriers, or surgery to prevent pregnancy. Techniques used to determine fertility include the cervical mucus ovulation method, the basal body temperature (BBT) method, the symptothermal method, standard days method, and 2-day method. Coitus interruptus or withdrawal is not considered a fertility awareness based method.
A client presents at the clinic and is interested in obtaining emergency contraception (EC). The nurse explains that EC must be used within 72 hours of unprotected sex to be effective. This is because: ECs can help prevent STIs. ECs can induce an abortion of a recently implanted embryo. ECs simply prevent embryo creation and uterine implantation from occurring in the first place. ECs are more effective than regular birth control.
ECs simply prevent embryo creation and uterine implantation from occurring in the first place. Rationale: ECs prevent the embryo creation and uterine implantation from occurring. There is no evidence that ECs have any effect on an already-implanted ovum or that they induce abortion. They do not protect against STIs and are less effective than regular birth control.
A nurse is conducting a class for high school students on preventing sexually transmitted infections (STIs). Which information would the nurse emphasize as the sole method for not contracting STIs? Using condoms Urinating immediately after intercourse Limiting sexual partners Engaging in abstinence
Engaging in abstinence Rationale:Although limiting sexual partners and using condoms can help in preventing STIs, abstinence is the only way to completely avoid contracting STIs. Urinating immediately after intercourse would be ineffective.
When educating a client about the dangers of STIs, the nurse emphasizes the risk of damage to other organs if the infection is left untreated. The nurse identifies possible liver damage that may result from which infection? HAV HBV PID HPV
HBV Rationale:Hepatitis B virus can result in serious, permanent liver damage. Treatment is generally supportive as no specific treatment for acute HBV infection exists. HAV is usually self-limiting and does not result in chronic infection. HPV has been linked to cervical cancer. PID can lead to fibrosis, scarring, loss of tubal function, ectopic pregnancy, pelvic abscess, infertility, recurrent or chronic episodes of the disease, chronic abdominal pain, pelvic adhesions, and depression
A client comes to the prenatal clinic for her first visit. Which screening would be most appropriate for the nurse to encourage the client to undergo? HPV HAV HBV HCV
HBV Rationale:Nurses should encourage women to undergo HBV screening at their first prenatal visit and repeat screening in the last trimester for women with high-risk behaviors to comply with the U.S. Preventive Services Task Force recommendations.
While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin? IgA IgG IgM IgE
IgA Rationale:The newborn largely depends on three immunoglobulins for defense: IgG, IgA, and IgM. A major source of IgA is human breast milk, so breastfeeding is believed to have significant immunologic advantages over formula feeding. IgG is the only immunoglobulin that crosses the placenta.
A middle-aged woman with a history of hypertension and high cholesterol levels asks the nurse about ways to reduce her risk for heart disease as she approaches menopause. Which area would the nurse emphasize as most important? Medications Lifestyle modification Screening Stress management
Lifestyle modification Rationale:Although medications and stress management can be helpful in reducing the woman's risk, lifestyle modifications are crucial to modify the woman's risk factors of hypertension and high cholesterol levels in preventing heart disease. Screening for heart disease would be important to identifying it early but would not help in reducing the woman's risk
A nurse is reviewing the history and physical examination findings of a postpartum woman and her female neonate. The neonate was healthy at birth but is now exhibiting signs of jaundice. Which factor(s) would the nurse assess to help identify the neonate suffers from jaundice? Select all that apply. Maternal TORCH infection Female gender of neonate Use of oxytocin during labor Maternal gestational diabetes Eastern European ethnicity
Maternal TORCH infection, Use of oxytocin during labor, Maternal gestational diabetes Rationale:Common risk factors for the development of jaundice include fetal-maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breastfeeding, drugs (such as diazepam, oxytocin, sulfisoxazole/erythromycin, and chloramphenicol), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, and intrauterine infections such as TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and other organisms).
A client presents with the possible symptoms of genital herpes simplex virus (HSV). When assessing the client, the nurse would anticipate which assessment measure as being least likely to aid in confirming the diagnosis? clinical findings physical examination Papanicolaou test viral culture
Papanicolaou test Rationale:Diagnosis of HSV is often based on clinical signs and symptoms and is confirmed by viral culture of fluid from the vesicles. The IgG/IgM antibody testing is frequently done for screening purposes. The Papanicolaou test is an insensitive and nonspecific diagnostic test for HSV and should not be relied on for diagnosis.
A nurse is reading a journal article about premenstrual syndrome (PMS) and the millions of women affected by it during their reproductive years. The nurse would expect to find approximately what percentage of women meeting the ACOG criteria for PMS? Correct Response: 75%
Rationale:It is estimated that up to 75% of reproductive-age women experience premenstrual symptoms that meet the ACOG criteria for PMS and up to 8% meet the diagnostic criteria for PMDD.
A nurse is conducting a class for a group of young adults at the health clinic about contraceptive options. The nurse determines that the teaching was successful when the group identifies which type as protective against sexually transmitted infections? Correct Response: Condom
Rationale:Only the condom provides protection against sexually transmitted infections. Intrauterine system, diaphragm, and contraceptive patch offer no protection.
A nurse is preparing a presentation for a client who is considering contraception. When discussing oral contraceptives, the nurse would identify which advantages? Select all that apply. Correct Response: - reduction in severe cramping - shortening of the menstrual period, - reduction in risk for osteoporosis.
Rationale:Oral contraceptives are associated with shortening and regulating the menstrual cycle, reducing severe cramping and bleeding, and reducing the risk for osteoporosis. They are also associated with an increased risk for breast cancer and migraine headaches
When teaching the client how to use a contraceptive sponge, the nurse must tell the client that leaving the sponge in place longer than 30 hours may lead to: Correct Response: toxic shock syndrome.
Rationale:The sponge provides protection for up to 12 hours but should not be left in place for more than 30 hours after insertion to avoid the risk of toxic shock syndrome.
The client presents reporting irregular menstrual cycles, bleeding between periods, mood swings, hot flashes, and vaginal tenderness. After an examination, the nurse suspects abnormal uterine bleeding. Which approach would be inappropriate? Correct Response: Tell the client she will need to learn to live with the problems.
Rationale:There are many treatable reasons for abnormal uterine bleeding. The client should be evaluated, and all related disorders should be treated as needed. Telling the client to just learn to live with it ignores the possibility that her symptoms are related to a serious but treatable condition
A woman is diagnosed with primary dysmenorrhea and is prescribed ibuprofen as part of her treatment plan. When teaching the woman about using this medication, which instruction would be important for the nurse to emphasize? Correct Response:"Start taking the medication when you first get your period."
Rationale:When taking a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, for dysmenorrhea, it is important for the woman to start therapy prophylactically and use sufficient doses to maximally suppress prostaglandin production. NSAIDs should be taken with food to prevent gastrointestinal upset. They should not be taken with aspirin because doing so can increase the risk of bleeding, which would be noted with black stools.
A pregnant woman who is HIV-positive comes to the clinic for an evaluation. As part of the visit, the nurse discusses ways the woman can boost her immune system. Which instruction(s) would the nurse likely suggest? Select all that apply. Getting 5 to 6 hours of sleep each night Taking rest periods during the day Eating small amounts of protein Staying away from crowded places Drinking at least 2 liters of fluid each day.
Taking rest periods during the day, Staying away from crowded places, Drinking at least 2 liters of fluid each day. Rationale:Ways to enhance the pregnant woman's immune system include: Getting adequate sleep each night (7 to 9 hours); avoiding infections (e.g., staying out of crowds, practicing good hand hygiene); decreasing stress; consuming adequate protein and vitamins; increasing fluid intake to 2 liters daily to stay hydrated; and planning rest periods throughout the day to prevent fatigue.
A nurse is engaged in primary prevention activities for human papillomavirus (HPV). The nurse would be most likely involved with which activity? educating about HPV testing in women over age 30 administering HPV vaccine teaching about the importance of regular Papanicolaou test encouraging treatment for genital warts
administering HPV vaccine Rationale:Primary prevention is aimed at preventing the disease or condition before it occurs, so giving the HPV vaccine would be a primary prevention activity. If the woman does not receive primary prevention with the vaccine, then secondary prevention would focus on education about the importance of receiving regular Papanicolaou tests and, for women over age 30, including an HPV test to determine whether the woman has a latent high-risk virus that could lead to precancerous cervical changes.
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? acrocyanosis respiratory rate of 50 breaths/minute asymmetrical chest movement short periods of apnea (less than 15 seconds)
asymmetrical chest movement Rationale:Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.
The nurse is preparing to administer medication therapy to a woman diagnosed with syphilis. The nurse would expect to administer: doxycycline. azithromycin metronidazole. miconazole.
azithromycin Rationale:Single-dose therapy is preferred for ease of use of azithromycin (Zithromax, Z-Pak) 1 g orally once; ceftriaxone (Rocephin) 250 mg IM once; ciprofloxacin (Cipro) 500 mg orally twice a day for 3 days; or erythromycin base 500 mg orally three times a day for 7 days. Penicillin G benzathine 2.4 million units IM weekly for 3 weeks can also be used for treatment, but client adherence can be challenging. Miconazole is used to treat candidiasis. Metronidazole is used to treat trichomoniasis. Doxycycline is used to treat chlamydia.
A nurse is presenting a program for a local women's group about STIs. When describing the information, the nurse would identify which infection as the most common cause of vaginal discharge? chlamydia syphilis candidiasis gonorrhea
candidiasis Rationale:Although vaginal discharge can occur with any STI, genital/vulvovaginal candidiasis is one of the most common causes of vaginal discharge. It is also referred to as yeast, monilia, and a fungal infection. It is not considered an STI because candida is a normal constituent in the vagina and becomes pathogenic only when the vaginal environment becomes altered.
A woman is to receive methotrexate and misoprostol to terminate a first-trimester pregnancy. When preparing the teaching plan for this client, the nurse understands that misoprostol works by: causing uterine contractions to expel the uterine contents. acting as a toxin to the trophoblastic tissue. dilating the cervix. blocking the action of progesterone on the endometrium
causing uterine contractions to expel the uterine contents. Rationale: Misoprostol works by causing uterine contractions, which help to expel the uterine contents. It has no effect on cervical dilation. Methotrexate is toxic to the trophoblastic tissue. Mifepristone blocks the action of progesterone, which is responsible for preparing the endometrium for implantation and then maintenance of the pregnancy.
A 24-year-old female client reports various issues. She admits to having unprotected sexual intercourse. Which findings would indicate a possible PID? Select all that apply. cervical motion tenderness adnexal tenderness constipation lower abdominal tenderness
cervical motion tenderness, adnexal tenderness, lower abdominal tenderness Rationale: Minimal criteria of PID as established by the CDC include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness.
A nurse is conducting a presentation for a local community group on sexually transmitted infections. The nurse determines that the group has understood the information when they identify which infection as the most commonly reported bacterial STI in the United States? chlamydia candidiasis gonorrhea syphilis
chlamydia Rationale:Chlamydia is the most commonly reported bacterial STI in the United States. The CDC estimates that over 3 million new cases occur each year.
A client has presented reporting symptoms that suggest a gonorrheal infection. After laboratory testing confirms this diagnosis, the nurse anticipates that the client will also be treated for which infection? HPV candidiasis chlamydia syphilis
chlamydia Rationale:The CDC recommends that any client being treated for gonorrhea should also be treated for chlamydia due to the common occurrence of co-infection of these two organisms.
A young couple is exploring their contraceptive options and is curious about using an intrauterine contraceptive device. The nurse explains that there are two types, one that uses hormones and one that uses: silicone. copper. potassium. magnesium.
copper Rationale:The implants contain either copper or progesterone to enhance their effectiveness. One or two attached strings protrude into the vagina so that the user can check its placement. Four IUCs are currently available in the United States: the copper ParaGard-TCu-380A, the levonorgestrel-releasing intrauterine systems (LNG-IUSs) marketed as Mirena and Kyleena, and the LNG-IUD marketed as Jaydess. The ParaGard-TCu-380A is approved for 10 years of use and is nonhormonal. Its mechanism of action is based on the release of copper ions, which alone are spermicidal. Additionally, the device causes an inflammatory action leading to a hostile uterine environment.
A nurse is working with a couple who is dealing with infertility. Which aspect would be most important for the nurse to consider? culture insurance restrictions emotional limits family budget
culture Rationale:Infertility is not only a physiologic problem but is also one that can initiate a life crisis that is experienced with psychologic, familial, social, and cultural consequences. Although insurance constraints, budget, and emotional aspects are important considerations, the manner in which the various cultures, ethnic groups, and religious groups perceive and manage infertility are very different and must be considered when working with couples who have been unable to conceive. Nurses need to include awareness of these differences in their counseling of the couples as they try to help them achieve their goal of getting pregnant.
The ability of the nurse to identify irregular findings during a physical assessment aids in rapid diagnosis and treatment of possible complications. The nurse assesses a newborn and notes tachycardia. The nurse notifies the health care provider based on the understanding that further assessment is necessary for which condition? anemia drug withdrawal infection hypothermia
drug withdrawal Rationale:Tachycardia may be found with volume depletion, cardiorespiratory disease, drug withdrawal, and hyperthyroidism.
The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? foramen ovale umbilical vessels ductus arteriosus ductus venosus
ductus arteriosus Rationale:During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.
The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? foramen ovale umbilical vessels ductus venosus ductus arteriosus
ductus arteriosus Rationale:During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.
Working at the local health clinic, the nurse recognizes that STIs can often result in PID. When a client with a history of repeat STIs presents to the clinic reporting severe abdominal cramping and bleeding, the immediate concern is to ensure the client does not have: ectopic pregnancy. endometriosis. genital herpes simplex. secondary urinary tract infection.
ectopic pregnancy. Rationale:Every day, more than one million people are newly infected with STIs that can lead to morbidity, mortality, and an increased risk of human immunodeficiency virus (HIV) acquisition. STIs may contribute to cervical cancer, infertility, ectopic pregnancy, chronic pelvic pain, and death.
When developing a program for STI prevention, which action would need to be done first? increasing the availability of resources interfering with the mode of transmission educating on how to promote sexual health getting individuals to change their behaviors
educating on how to promote sexual health Rationale:The key to successful treatment and prevention of STIs is education to promote sexual health. Behavior changes, increasing the availability of resources, and interfering with modes of transmission are important, but all of these require education.
A nurse is reviewing the history and physical examination of a client diagnosed with secondary dysmenorrhea for possible associated causes. Which etiology would the nurse need to keep in mind as being the most common? multigravida status perimenopause hormonal imbalance endometriosis
endometriosis Rationale:Secondary dysmenorrhea is painful menstruation due to pelvic or uterine pathology. Endometriosis is the most common cause of secondary dysmenorrhea. Other recognized causes include adenomyosis, fibroids, pelvic infection, an intrauterine device, cervical stenosis, or congenital uterine or vaginal abnormalities.
The nurse is assessing a couple who have come to the health care facility because they have been unable to conceive a child. When assessing the woman, the nurse would identify which factor as increasing the woman's risk for infertility? patient fallopian tubes endometriosis dysmenorrhea age of 25 years
endometriosis Risk factors for infertility include endometriosis, age older than 27 years, tubal blockages, weight variations, hormonal imbalances, fibroids, reduced oocyte quality, chromosomal abnormalities, congenital anomalies of the cervix and uterus, immune system disorders, chronic illnesses, sexually transmitted infections, history of PID, smoking and alcohol consumption, multiple miscarriages, and psychological stress. Dysmenorrhea is not an associated risk factor.
The nurse is planning to speak at a local community center to a group of middle-aged women about osteoporosis. Which measure would the nurse be sure to include as effective in reducing the risk for osteoporosis? engaging in daily weight-bearing exercise decreasing vitamin D intake drinking at least 1 glass of wine per day limiting intake of cholesterol and saturated fats
engaging in daily weight-bearing exercise Rationale:Engaging in daily weight-bearing exercise such as walking helps to reduce a woman's risk for osteoporosis. To prevent osteoporosis, women should increase their calcium and vitamin D intake. Avoiding excessive alcohol ingestion helps prevent osteoporosis. Limiting intake of cholesterol and saturated fats helps reduce the risk for cardiovascular disease, not osteoporosis.
A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame? first 36 days of life first 28 days of life first 2 months of life first 3 weeks of life
first 28 days of life Rationale:The neonatal period is defined as the first 28 days of life. During this time period numerous physiologic changes occur as the infant adapts to the new environment.
A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? protein glucose brown fat carbohydrate
glucose Rationale:Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Stored protein, brown fat, or carbohydrate are not associated with energy production in the newborn.
A newborn is diagnosed with ophthalmia neonatorum. The nurse understands that this newborn was exposed to which infection? human immunodeficiency virus syphilis Candida albicans gonorrhea
gonorrhea Rationale:Gonorrhea can be transmitted to the newborn in the form of ophthalmia neonatorum during birth by direct contact with gonococcal organisms in the cervix. The newborn would develop congenital syphilis if exposed in utero. Exposure to Candida would cause thrush in the newborn. Exposure to HIV during gestation could lead to the birth of an HIV-positive newborn.
Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? red blood cells: 3,500,000/uL hemoglobin: 17.5 g/dl platelets: 600,000/uL white blood cells: 5,000/mm3
hemoglobin: 17.5 g/dl Rationale:Hemoglobin typically ranges from 17 to 20 g/dl. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL.
When the nurse is describing the events that occur in a newborn when he or she experiences a cold environment, which event would the nurse identify as occurring first? increased cardiac output increased release of norepinephrine breakdown of triglycerides increased blood flow through brown fat
increased release of norepinephrine Rationale:When the newborn experiences a cold environment, the release of norepinephrine increases. This in turn stimulates brown fat metabolism by the breakdown of triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat.
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence? loss of blood volume due to hemorrhage inadequate suctioning of the mouth and nose of the newborn lack of thoracic compressions during birth prolonged unsuccessful vaginal birth
lack of thoracic compressions during birth Rationale:A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.
The nurse is aware that the infant's circulatory dynamics during transition can be greatly affected by which action? delayed clamping of the umbilical cord by at least 5 minutes late clamping of the umbilical cord after 3 minutes giving the infant oxygen as needed quickly clamping the cord as soon as possible
late clamping of the umbilical cord after 3 minutes Rationale:Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition. Recent studies indicate that the benefits of delayed cord clamping include improving the newborn's cardiopulmonary adaptation, preventing iron-deficient anemia in full-term newborns without increasing hypervolemia-related risks and increased iron stores, increasing blood pressure, improving oxygen transport, and increasing red blood cell flow. Although a tailored approach is required in the case of cord clamping, current available data suggests that delayed cord clamping offers the newborn many benefits physiologically which include at least a 30 percent increase in blood volume for term infants and a 50 percent increase in preterm infants; improvement of systemic blood pressure; increase in the cerebral oxygen index; higher hemoglobin levels at 24 to 48 hours of age and increased serum iron levels at 4 to 6 months.
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? limited voluntary muscle activity thick skin with deep lying blood vessels enhanced shivering ability expanded stores of glucose and glycogen
limited voluntary muscle activity Rationale:Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.
A nurse is describing the many changes a newborn will go through during his or her first couple of weeks after birth. The nurse explains how the functions of the placenta are taken over by which organ? cardiovascular system kidneys liver intestine
liver Rationale:At birth, the newborn's liver, not the intestine, cardiovascular system, or kidneys, assumes the functions that the placenta handled during fetal life. This includes iron storage, carbohydrate metabolism, blood coagulation, and conjugation of bilirubin.
The client is interested in using an injectable contraceptive that works by suppressing pituitary secretions. The nurse provides the client with literature and discusses which contraceptive with her? medroxyprogesterone acetate etonogestrel norelgestromin/ethinyl estradiol levonorgestrel/ethinyl estradiol
medroxyprogesterone acetate Rationale: Medroxyprogesterone acetate is an injectable form of a progesterone-only contraceptive that is given every 12 weeks. It works by suppressing ovulation and the production of FSH and LH by the pituitary gland. Etonogestrel is an implantable form contraceptive. Norelgestromin/ethinyl estradiol is a patch-type contraceptive, and levonorgestrel/ethinyl estradiol is an oral contraceptive that uses a 365-day combination dosing.
A client is diagnosed with trichomoniasis infection. The nurse prepares to teach the client about which medication? metronidazole miconazole penicillin G fluconazole
metronidazole Rationale:Oral metronidazole or tinidazole is used to treat trichomoniasis. Penicillin G may be used to treat syphilis. Miconazole and fluconazole are used to treat candidiasis.
A nurse is assessing a newborn and observes the newborn bringing his hand up to his mouth. The nurse interprets this finding as which behavioral response? orientation self-quieting ability motor maturity habituation
motor maturity Rationale:Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Bringing the hand up to the mouth is an example of good motor organization. The response of newborns to stimuli is called orientation. They become more alert when they sense a new stimulus in their environment. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. It is a measure of how well and appropriately an infant responds to the environment. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.
The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? thermoregulation thermoconduction nonshivering thermogenesis shivering thermogenesis
nonshivering thermogenesis Rationale:The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. When the newborn is in a cold environment, the blood flow is increased through the brown fat, which warms the blood and in turn helps warm the infant.
When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. attachment to parents orientation self-quieting ability habituation adequate feedings
orientation, self-quieting ability, habituation Rationale:Expected newborn behaviors include orientation, habituation, motor maturity, self-quieting ability, and social behaviors. Any deviation in behavioral responses requires further assessment because it may indicate a complex neurobehavioral problem.
When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate? between the scapulae over the liver over the opposite hip in the mediastinal area
over the liver Rationale:To obtain accurate assessment of whole body temperature, a skin temperature probe should be placed over the liver if the newborn is supine or in the side-lying position. Bony areas such as the hip or areas with brown fat such the mediastinum or between the scapulae should be avoided because these areas do not give accurate readings.
A nurse is explaining to new parents about the numerous changes that occur shortly after birth to the newborn. When describing how the ductus arteriosus closes, the nurse explains that which factor is most important to assist in its closure? oxygen clamping the umbilical cord breathing start breastfeeding immediately
oxygen Rationale:The ductus arteriosus becomes functionally closed within the first few hours after birth. Oxygen is the most important factor in controlling its closure. Closure depends on the high oxygen content of the aortic blood resulting from aeration of the lungs at birth.
A client is diagnosed with endometriosis. As part of the teaching plan, the nurse is explaining the condition, including the ways that the diagnosis would be confirmed. The nurse determines that the teaching was successful when the client states that which test would confirm the diagnosis? Papanicolaou test bimanual exam pelvic ultrasound pelvic laparoscopy
pelvic laparoscopy Rationale:A thorough history and pelvic examination may lead the health care practitioner to suspect endometriosis; however, the only certain method of diagnosing it is by visualizing it via a laparoscopy. A tissue biopsy can be obtained at this time and examined microscopically to confirm it. A Papanicolaou test would be done to rule out cervical cancer. A pelvic ultrasound would not be definitive for endometriosis.
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? orientation to surroundings voluntary movements crying response reflex
reflex Rationale:The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? voluntary movements reflex orientation to surroundings crying response
reflex Rationale:The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.
A nurse is conducting a program about genital herpes infection at a community clinic. The nurse determines that additional discussion is needed when the group identifies which activity as a means of transmission? sexual contact kissing sharing contaminated needles giving vaginal birth
sharing contaminated needles Rationale:Herpes simplex virus is transmitted primarily by direct contact with an infected individual who is shedding the virus and may include kissing, sexual contact, and vaginal birth. Sharing contaminated needles is a means of transmitting HIV.
The mother has given birth to a premature infant at 30 weeks. To ensure the alveoli can function properly, the infant needs to be evaluated for: surfactant. oxygen. blood flow. hematocrit.
surfactant. Rationale:Surfactant is a surface tension-reducing lipoprotein found in the newborn's lungs that prevents alveolar collapse at the end of expiration and loss of lung volume. Surfactant provides the lung stability needed for gas exchange. Oxygen, hematocrit, and blood flow are unrelated.
A couple has chosen fertility awareness as their method of contraception. The nurse explains that the unsafe period for them during the menstrual cycle would be at which time? five days after the first day of the menstrual cycle three days before and three days after ovulation six days before the onset of menstruation midway between the normal menstrual cycle
three days before and three days after ovulation Rationale:Typically, the unsafe period during the menstrual cycle is approximately 3 days before and 3 days after ovulation. An ovum is released from the ovary 14 days before the next menstrual period
A woman comes to the clinic reporting intense pruritus and a thick curd-like vaginal discharge. On examination, white plaques on observed on the vaginal wall. The nurse suspects which condition? vulvovaginal candidiasis trichomoniasis chlamydia bacterial vaginosis
vulvovaginal candidiasis Rationale:Pruritus, a thick, curd-like vaginal discharge, and white plaques on the vaginal wall are characteristic of vulvovaginal candidiasis. Trichomoniasis is characterized by a heavy yellow or green or gray frothy or bubbly discharge. Bacterial vaginosis is characterized by a thin white homogeneous vaginal discharge. Chlamydia is usually manifested by a mucopurulent vagina discharge.
When teaching a woman diagnosed with genital herpes lesions, the nurse would include which measure? washing hands with soap and water after touching lesions refraining from using condoms during sexual intercourse applying ice packs to the area for comfort drying lesions with a hair dryer set on hig
washing hands with soap and water after touching lesions Rationale:Hand washing with soap and water after touching lesions is essential to avoid autoinoculation. Extremes of temperature, such as ice or hot packs, to the genital area should be avoided. Drying the lesions is appropriate, but the hair dryer should be set on a low setting. Condoms should be used with all new or noninfected partners.
The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? greenish, tarry, thick black stool yellow-green, pasty, unpleasant-smelling stool sour-smelling, yellowish-gold stool thin, yellowish, seedy brown stool
yellow-green, pasty, unpleasant-smelling stool Rationale:The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool.
