OB Final Exam Evolve Questions

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs are:

Abdominal distention, temperature instability, and grossly bloody stools. Rationale: Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall.

Which of the following clinical presentations is consistent with the physical finding of carcinoma in situ (CIS)?

Abnormal cells noted in the full thickness of the epithelium Rationale: CIS is defined as abnormal cells noted in the full thickness of the epithelium. Abnormal cells located in the uterine fundus reflect dysplasia but do not define CIS. Abnormal cells located in the lower one third of the epithelium indicate cervical intraepithelial neoplasia (CIN) 1.

The rate of fertility declines dramatically after age 35. While explaining the cause of this rapid decline in fertility to the client, the nurse is aware that the primary reason for this is related to:

Abnormalities of oocytes Rationale: By age 40, the total number of ovarian follicles is diminishing and the quality of the remaining eggs is poor. Endometriosis is more common in women who delay childbearing until after age 30. Like infection and metabolic disease, it is a cumulative factor that may contribute to age-related infertility.

The process by which people retain some of their own culture while adopting the practices of the dominant society is known as:

Acculturation. Rationale: Acculturation is the process by which people retain some of their own culture while adopting the practices of the dominant society. This process takes place over the course of generations. Assimilation is a loss of cultural identity. Ethnocentrism is the belief in the superiority of one's own culture over the cultures of others. Cultural relativism recognizes the roles of different cultures.

In the 1970s rape-trauma syndrome (RTS) was identified as a cluster of characteristics, symptoms, and related behaviors seen in the weeks and months after a rape. Which pattern of responses would not apply to a victim of rape?

Acute phase: rearranging Rationale: Reorganization is not a phase of RTS. Disorganization is the first phase of RTS, which can last for several days up to 3 weeks. Reactions such as shock, denial, and disbelief are common. The rape survivor feels embarrassed, degraded, angry, and vengeful. The outward adjustment phase is next. The survivor appears to have resolved her crisis. She needs to regain control over her life and may return to work, move, or buy a weapon to defend herself. The third phase is reorganization. Suppression of feelings and emotions starts to deteriorate, and the woman may become depressed and anxious.

An Rh-negative woman has a miscarriage during the 8th week of pregnancy and a D&C is required. Which priority intervention would be required in the recovery period following the surgical procedure?

Administer RhoGAM. Rationale: Administering RhoGAM would be a priority intervention because the patient is Rh negative and there is no way to determine the Rh status of the fetus. Type and screen would not be indicated as if the patient were to require a blood transfusion; this would not reflect holding blood. Although it would be important to maintain the patient's hydration level, it could be done if needed via the parenteral route. Fundal massage would not be indicated at 8 weeks of gestation.

The nurse is observing a postpartum patient who has been bleeding excessively during the first hour, saturating multiple pads. Which interventions would the nurse anticipate that the physician would order?

Administer oxygen via nonrebreather mask @ 10 L/minute Insert a secondary intravenous line access Rationale: Administration of oxygen @ 10L/minute via nonrebreather mask would be an anticipated order, as would insertion of a secondary line access for administration of fluids, blood, and/or medications. Although documentation of findings in a health care record is required, this is part of the nursing role and does not require an order by the physician. With regard to the presence of hypovolemic shock, intravenous fluids would be increased and maintained. The flow rate would not typically be decreased unless there was another comorbidity leading to potential fluid overload. Type & Screen would not be an anticipated order because no blood would be held for use; rather a Type & Cross order would be anticipated.

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?

Administration of blood Rationale: Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement (not volume restriction), blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because it could contribute to more areas of bleeding. Steroids are not indicated for the management of DIC.

A pregnant patient experiences thyroid storm following delivery of her infant. What interventions would the nurse anticipate to be ordered by the physician?

Administration of oxygen Antipyretics PTU Rationale: Oxygen would be provided, antipyretics would be given to reduce fever, and PTU would be administered. IV fluids would be administered to the patient in order to reverse the hypotension that the patient would be experiencing. Synthroid would not be given because it is used to treat hypothyroidism, and with thyroid storm, the patient is suffering from hyperthyroidism.

During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurse's first response should be to:

Advise the woman of mandatory state reporting laws pertaining to abuse and confidentiality. Rationale: Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation. Many states have mandatory reporting laws for health care providers. It is important to inform the woman that you may need to report what she has told you. Nurses should be knowledgeable about the reporting requirements of the state in which they practice.

Which priority action would be most beneficial in helping a couple deal with fetal loss following the delivery of a stillborn?

Allow the parents to hold and view the baby following delivery if they so request. Rationale: Bonding with the stillborn by holding and viewing after delivery is well documented by research to provide a source of comfort and closure. Although it will be important for family members to comfort the couple, it is more important for the family unit to be alone to adapt to the delivery. Providing a quiet environment is important but it not the priority action to be taken at this time. Taking a photograph is important as a keepsake but it is typically taken before the stillborn leaves the hospital..

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be:

Alteration in the pattern of fetal movement Rationale: An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy. Constipation is a normal discomfort of pregnancy that occurs in the second and third trimesters. Heart palpitations are a normal change related to pregnancy; they are most likely to occur during the second and third trimesters. As the pregnancy progresses, edema in the ankles and feet at the end of the day is not uncommon.

A thrombosis results from the formation of a blood clot or clots inside a blood vessel and is caused by inflammation or partial obstruction of the vessel. Three thromboembolic conditions are of concern during the postpartum period; which of the following is not?

Amniotic fluid embolism (AFE) Rationale: An AFE occurs during the intrapartum period, when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis, the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis, occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs.

A patient who is breastfeeding has been diagnosed with Gonorrhea. Which treatment plan should be instituted?

Amoxicillin 500 mg three times a day for 7 days and ceftriaxone 250 mg IM injection Rationale: Amoxicillin or ceftriaxone can be part of the treatment plan for gonorrhea but the patient should be treated empirically for chlamydia as well. Dual therapy with amoxicillin and ceftriaxone can be used for treatment of gonorrhea and empirical treatment of chlamydia. Benzathine penicillin is indicated for treatment of syphilis for the lactating patient.

The majority of ectopic pregnancies are located in the:

Ampulla. Rationale: A pregnancy within the uterus would be considered a normal pregnancy. Implantation of the pregnancy at the cervical os would be a significant abnormality. The majority of ectopic pregnancies, approximately 80%, are located in the ampulla or largest portion of the tube.

An Apgar score of 10 at 1 minute after birth indicates:

An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. Rationale: A score of 10 at 1 minute of life indicates excellent transition to extrauterine life; however, the assessment needs to be repeated at 5 minutes of life. An infant in need of resuscitation has a very low Apgar score. Apgar scores do not predict neurologic outcome but are useful for describing the newborn's transition to extrauterine environment.

Women with severe and persistent mental illness are likely to be more vulnerable to being involved in controlling and/or violent relationships. However, many women experience mental health problems as a result of long-term abuse. The psychologic consequences of continued abuse do not include:

Bipolar disorder. Rationale: Substance abuse is a common method of coping with long-term abuse. The abuser is also more likely to use alcohol and other chemical substances. PTSD is the most prevalent mental health sequela of long-term abuse. The traumatic event is persistently reexperienced through distress recollection and dreams. Eating disorders, depression, psychophysiologic illness, and anxiety reactions are all mental health problems associated with repeated abuse. Bipolar disorder is a specific illness (also known as

A nurse counseling a client with endometriosis understands which statement regarding the management of endometriosis is not accurate?

Bone loss from hypoestrogenism is not reversible. Rationale: Bone loss is mostly reversible within 12 to 18 months after the medication is stopped. Such masculinizing traits as hirsutism, a deepening voice, and weight gain occur with danazol but are reversible. Surgical intervention is often needed when symptoms are incapacitating; the type of surgery is influenced by the woman's age and desire to have children. Treatment is not needed for women without pain or the desire to have children.

Which finding is not associated as a health risk with menopause?

Breast cancer Rationale: Breast cancer may be associated with the use of hormone replacement therapy for women who have a family history of breast cancer. Osteoporosis is a major health problem in the United States; it is associated with an increase in hip and vertebral fractures in postmenopausal women. A woman's risk for development of and death from cardiovascular disease increases significantly after menopause. Women tend to become more sedentary in midlife. The metabolic rate decreases after menopause, so an adjustment in lifestyle and eating patterns may be required.

When providing health education to the client, the nurse understands that an example of the secondary level of prevention is:

Breast self-examination (BSE). Rationale: Infant car seats and immunizations are examples of primary prevention. BSE is an example of secondary prevention, which includes health screening measures for early detection of health problems. Support groups are an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., Down syndrome).

The concept of tandem feeding is based on:

Breastfeeding an infant and an older sibling during the same period. Rationale: In tandem feeding, a mother nurses both an infant and an older child during the same period.

Which statement is not accurate regarding the effect of breastfeeding on the family or society at large?

Breastfeeding costs employers in terms of time lost from work. Rationale: Less time is lost from work by breastfeeding mothers, in part because infants are healthier than bottle-fed infants. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment, and it saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Also, breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

Health care providers demonstrate a variety of reactions to lesbian couples, including failure to acknowledge the "other mother's" role in pregnancy, birth, and parenting. Integration of the nonchildbearing partner into care includes offering the same opportunities afforded male partners of heterosexual women. Which opportunity could not be provided to male partners?

Breastfeeding the infant Rationale: An option not available to male partners is to actually breastfeed the infant. The nonchildbearing female partner can stimulate milk production through induced lactation using medications and regular pumping. A supplemental feeding device containing expressed breast milk or formula can be used to provide additional milk to the breastfeeding infant. Labor support is a very appropriate role for the "other mother" or "co-parent." Pregnancy for lesbian couples is an intentional event, and generally both mothers will want to be very involved. As with heterosexual couples, if institutional policy allows, the nonbiologic mother should be allowed to cut the umbilical cord after delivery. Like any heterosexual parents, lesbian couples face challenges in adjusting to life with a new baby. Encouraging rooming-in assists with this transition.

With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is:

Breastfeeding. Rationale: Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also helps the woman return to her prepregnant weight sooner.All breastfed infants should be fed on demand. Use of lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period.

With regard to breathing techniques during labor, maternity nurses should be aware that:

Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. Rationale: First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor, when the cervix is dilated 8 to 10 cm. Patterned-paced breathing can sometimes lead to hyperventilation.

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:

Change in position. Rationale: Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This pressure reduces venous return to the woman's heart, as well as cardiac output, and subsequently lowers her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration, regional anesthesia, and intravenous analgesic may all reduce maternal cardiac output.

Which finding is associated with endometriosis?

Chocolate cyst Rationale: A chocolate cyst is seen in endometriosis as a result of old blood. The chandelier sign is associated with PID. Chadwick sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is a presumptive sign of pregnancy.With endometriosis, fluid is found in the cul-de-sac, which can be associated with ectopic pregnancy and ovarian disease.

Which of the following would be considered to be an intrapartum risk factor for neonatal sepsis?

Chorioamnionitis Rationale: Chorioamnionitis would be considered to be an intrapartum risk factor. The other conditions described are neonatal risk factors.

Which of the following presentations is associated with early pregnancy loss, occurring in less than 12 weeks gestation?

Chromosomal abnormalities Hypothyroidism Rationale: 50% of early pregnancy loss results from genetic abnormalities. Hypothyroidism and antiphospholipid syndrome are associated with early pregnancy loss. Caffeine use is associated with second-trimester losses as a result of maternal behavior. Infection is not a likely source of early pregnancy loss. Cystitis in not associated with early pregnancy loss.

A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:

Cleanse eyes from inner to outer canthus before administration if necessary. Rationale: The newborn's eyes should be cleansed if necessary before the administration of erythromycin ointment. Instillation of the ointment can be delayed for up to 2 hours to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin ointment should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Rationale: Gentle cleansing with warm water, not wipes, and application of petroleum jelly at each diaper change are appropriate care for an infant who has had a circumcision. If bleeding occurs, gentle pressure should be applied to the site of the bleeding with a sterile gauze square. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.

When performing vaginal examinations on a laboring woman, the nurse should be guided by what principle?

Cleanse the vulva and perineum before and after the examination as needed. Rationale: Cleansing will reduce the possibility that secretions and microorganisms will ascend into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to prevent infection. Vaginal examinations should be performed only as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present, because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

Which finding supports the diagnosis of pathologic jaundice?

Clinical jaundice evident within 24 hours of birth Rationale: Clinical jaundice evident within 24 hours of birth supports a diagnosis of pathologic jaundice. This diagnosis is also supported by serum bilirubin concentrations greater than 4 mg/dL in cord blood; total serum bilirubin levels that increase by more than 5 mg/dL in 24 hours; and a serum bilirubin level in a preterm newborn that exceeds 10 mg/dL.

The term used to describe professional interaction among health care providers in the clinical nursing practice is:

Collegiality

In order to reassure and educate pregnant clients about changes in their blood pressure, maternity nurses should be aware that:

Compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the later stage of term pregnancy. Rationale: In addition to hemorrhoids, compression of the iliac veins and inferior vena cava by the uterus also leads to varicose veins in the legs and vulva. The tightness of a cuff that is too small produces a reading that is too high; similarly, the looseness of a cuff that is too large results in a reading that is too low. Because maternal positioning affects readings, each blood pressure measurement should be obtained in the same arm and with the woman in the same position. The systolic blood pressure generally remains constant but may decline slightly as pregnancy advances. The diastolic blood pressure first drops and then gradually increases.

A nurse is performing a pulse oximetry reading on a newborn to test for:

Congenital heart disease. Rationale: Pulse oximetry can be used to determine the presence of congenital heart disease in healthy newborns. Routine screening of newborns is done via the Guthrie heelstick test to look for certain metabolic diseases such as PKU, sickle cell disease, and thalassemia.

In the use of a two-client model for a cancer patient who is pregnant, which emphasis would be used for clinical ethical decision making?

Consideration would focus on promotion of fetal well-being. Rationale: In a two-client model, the focus would be on fetal well-being. A one-client model would focus on the maternal-fetal unit.

When counseling a client about getting enough iron in her diet, the maternity nurse should tell her that:

Constipation is common with iron supplements. Rationale: Constipation can be a problem with iron supplements. Milk, coffee, and tea actually inhibit iron absorption when consumed at the same time as iron. Vitamin C promotes iron absorption. Children who ingest iron can get very sick and even die.

When a nurse is unsure about how to perform a client care procedure, the best action would be to:

Consult the agency procedure manual and follow the guidelines for the procedure. Rationale Each nurse is responsible for his or her own practice. Relying on another nurse may not always be safe practice. Physicians are responsible for their own client care activity. Nurses may follow safe orders from physicians, but they are also responsible for the activities that they as nurses are to carry out. Information provided in a nursing textbook is basic information for general knowledge and may not reflect the current standard of care or individual state or hospital policies. Each nurse is obligated to follow the standards of care for safe client care delivery. It is always best to follow the agency's policies and procedures manual when seeking information on correct client procedures. These policies should reflect the current standards of care and state guidelines.

The nurse who provides preconception care understands that it:

Could include interventions to reduce substance use and abuse. Rationale: Preconception care is designed for all women of childbearing potential. Risk factor assessment includes financial resources and environmental conditions at home and work. Health promotion can include teaching about safe sex. If assessments indicate a drug problem, treatment can be suggested or arranged.

With regard to the respiratory development of the newborn, nurses should be aware that:

Crying increases the distribution of air in the lungs Rationale: Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, helping draw air into the lungs. The positive pressure created by crying helps keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. They are natural nose breathers and may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

A woman has preinvasive cancer of the cervix. In discussing available treatments, the nurse includes:

Cryosurgery Rationale: Cryosurgery, laser surgery, and loop electrosurgical excision procedure (LEEP) are several techniques used to treat preinvasive lesions. A hysterectomy is performed if the cancer has extended beyond the cervix. Women with positive pelvic lymph nodes (indicating invasive cancer) usually receive whole-pelvis irradiation. Colposcopy, examination of the cervix with a stereoscopic binocular microscope that magnifies the view of the cervix, would have been done as part of the diagnosis of preinvasive cancer of the cervix.

The uterus is a muscular pear-shaped organ that is responsible for:

Cyclic menstruation. Rationale: The uterus is an organ for reception, implantation, retention, and nutrition of the fertilized ovum; it also is responsible for cyclic menstruation. Hormone production and fertilization occur in the ovaries. Sexual arousal is a feedback mechanism involving the hypothalamus, the pituitary gland, and the ovaries.

A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems as well as sensations of bearing down and of something in her vagina. The nurse realizes that the woman most likely is suffering from:

Cystoceles and/or rectoceles

An effective relief measure for primary dysmenorrhea is to:

Decrease intake of salt and refined sugar about 1 week before menstruation is about to occur. Rationale: Decreasing intake of salt and refined sugar can reduce fluid retention. Staying active is helpful because it facilitates menstrual flow and increases vasodilation to reduce ischemia. Prostaglandin inhibitors should be started a few days before the onset of menstruation. OCPs are beneficial in relieving primary dysmenorrhea due to inhibition of ovulation and prostaglandin synthesis.

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:

Degree of glycemic control during pregnancy. Rationale: Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. Although advanced maternal age may pose some health risks, the most important factor for the woman with pregestational diabetes remains the degree of glycemic control during pregnancy. The number of years since diagnosis and the amount of insulin required are not as relevant to outcomes as the degree of glycemic control.

Which description of the phases of the second stage of labor is accurate?

Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Rationale: The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or "laboring down" period, at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. Von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels rise naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum as levels of von Willebrand factor (vWf) and factor VIII fall. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is:

Desmopressin Rationale: Desmopressin is the primary treatment of choice. This hormone, which can be administered orally, nasally, and intravenously, promotes the release of factor VIII and vWf from storage. Treatment with cryoprecipitate or with plasma products such as factor VIII and vWf is acceptable, but because of the associated risk of possible viruses from donor blood products, other modalities are considered safer. Although the administration of the synthetic prostaglandin in Hemabate is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

Nurses, certified nurse-midwives, and other advanced practice nurses have the knowledge and expertise to assist women in making informed choices regarding contraception. A multidisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. Which action should the nurse take first when meeting with a new client to discuss contraception?

Determine the woman's level of knowledge about contraception and commitment to any particular method. Rationale: All of these actions are part of the assessment, but determination of the woman's level of knowledge regarding contraception and her commitment to a method is the primary step and is necessary before completing the process and moving on to a nursing diagnosis. Once the client's level of knowledge is determined, the nurse can interact with her to compare options, reliability, cost, comfort level, protection from sexually transmitted infections (STIs), and a partner's willingness to participate. Data about frequency of coitus should include the number of sexual partners, level of partner contraceptive involvement, and any partner objections. A woman's willingness to touch her genitals and cervical mucus is a key factor for the nurse to discuss only if the client expresses interest in using one of the fertility awareness methods of contraception.

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that:

Dietary management involves distributing nutrient requirements over three meals and two or three snacks. Rationale: Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative.Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control.

A nurse is working with a diabetic patient who recently found out she is pregnant. In coordinating an interdisciplinary team to help manage the patient throughout the pregnancy, the nurse would include:

Dietician Perinatologist Nephrologist Rationale: An internal medicine practitioner rather than family practice physician would be included on the interdisciplinary care team. A dietician would be included to help the patient with dietary planning, a perinatologist to take care of the maternal-fetal unit, and a nephrologist to monitor renal function. There is no need for an occupational therapist or a speech therapist unless other issues arise.

Fibrocystic changes in the breast most often appear in women in their 20s and 30s. The etiology is not known, but it may be an imbalance of estrogen and progesterone. The nurse who cares for a client with such changes should be aware that treatment modalities are conservative. One proven modality that may provide relief is:

Diuretic administration Rationale: Diuretic administration plus a decrease in sodium and fluid intake are recommended. Although not supported by research, eliminating dimethylxanthines (caffeine) from the diet has been advocated. Smoking should also be avoided, and alcohol consumption reduced. Vitamin E supplements are recommended; however, the client should avoid megadoses because this is a fat-soluble vitamin. Pain relief measures include applying heat to the breast, wearing a supportive bra, and taking nonsteroidal anti-inflammatory drugs.

The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis?

Doppler blood flow analysis Rationale: Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high risk pregnancy due to intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed in a woman whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although it may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.

The Centers for Disease Control and Prevention (CDC)-recommended medication for the treatment of chlamydia is:

Doxycycline rationale: Doxycycline is effective for treating chlamydia; however, it should be avoided if a woman is pregnant. Podofilox is a recommended treatment for nonpregnant women diagnosed with human papillomavirus infection. Acyclovir is recommended for genital herpes simplex virus infection. Penicillin is the preferred medication for syphilis.

Which factor increases the risk of complications for infants of diabetic mothers?

Duration of maternal disease Rationale: The duration and severity of maternal disease are significant factors in increasing the risk for complications in infants of diabetic mothers. Glycemic control would be a positive factor indicating that blood glucose levels were maintained within normal range. A hemoglobin A

A nurse is examining a patient who has been admitted for possible ectopic pregnancy who is approximately 8 weeks pregnant. Which finding would be a priority concern?

Ecchymosis noted around umbilicus Rationale: Because this patient is most likely in the early stages of pregnancy, FHT would not be able to be auscultated at this time. Scant vaginal bleeding would not be a priority concern but should still be monitored by the nurse. Ecchymosis around the umbilicus indicates Cullen sign, which indicates hematoperitoneum, and may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.

Which findings could be considered to be a barrier to a pregnant woman seeking prenatal care?

Economic cost of health care. Patient's cultural beliefs do not include prenatal care as being valued. Patient had a bad experience the last time she went to a doctor for care. Rationale: Economic factors can delay the onset of health care treatment. A patient's cultural beliefs and values may be a barrier to seeking prenatal care if her culture does not perceive any inherent value in prenatal care. If the patient had a bad prior experience with a health care provider, it may be a barrier to seeking future care. The fact that this patient is multilingual does not necessarily represent a barrier to seeking prenatal care. Although the patient may prefer to be cared for by a midwife, this fact cannot be considered a barrier to seeking prenatal care because it demonstrates a patient's choice.

With regard to systemic analgesics administered during labor, nurses should be aware that:

Effects on the fetus and newborn can include decreased alertness and delayed sucking. Rationale: Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

Which behaviors would be exhibited during the letting-go phase of maternal role adaptation?

Emergence of family unit Sexual intimacy relationship continuing Defining one's individual roles Rationale: Emergence of family unit, sexual intimacy relationship continuing, and defining one's individual roles represent interdependent behaviors associated with the letting-go phase. Dependent behaviors are exhibited in the taking-in phase. Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors.

The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. On the basis of this finding, the nurse should:

Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. Rationale: Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. The infant is not undernourished, and the physician does not need to be notified. Breastfeeding is effective, and bottle feeding does not need to be initiated at this time.

When obtaining a health history, the nurse should be aware that the most common malignancy of the reproductive system is:

Endometrial cancer Rationale: Endometrial cancer occurs most frequently in Caucasian women and after menopause. Ovarian cancer is the most malignant reproductive system cancer and accounts for the most deaths. Cancers of the vulva and vagina are relatively rare. Certain viral infections and sexually transmitted diseases create risks for cervical cancer.

Vitamin K is given to the newborn to:

Enhance the ability of blood to clot. Rationale: Newborns have a deficiency of vitamin K until intestinal bacteria that produce it are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels, increase the production of red blood cells, or stimulate the formation of surfactant.

Over-the-counter (OTC) pregnancy tests usually rely on which technology to test for human chorionic gonadotropin (hCG)?

Enzyme-linked immunosorbent assay (ELISA) Rationale: OTC pregnancy tests use ELISA for its one-step, accurate results. Radioimmunoassays test for the subunit of hCG in serum or urine samples and must be performed in the laboratory. The radioreceptor assay is a serum test that measures the ability of a blood sample to inhibit the binding of hCG to receptors. The latex agglutination test in no way determines pregnancy. Rather it is done to detect specific antigens and antibodies.

In which culture is the father more likely to be expected to participate in the labor and delivery?

European-American Rationale: Asian-American fathers do not actively participate in labor or birth. African-American men view pregnancy as a sign of virility; however, they may be less likely to participate actively in labor or birth. European-Americans expect the father to take a more active role in the labor and delivery than the other cultures. Hispanic men often view labor and birth as a female affair.

Following a vaginal delivery, the patient tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the patient that:

Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. Weight loss diets are not recommended for women who breastfeed. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. Rationale: Weight loss diet plans are not recommended for women who are breastfeeding because they can lead to depletion of reserves and nutrient stores and decreased milk production. Breastfeeding mothers need to increase their caloric intake by 400-500 calories/day to ensure adequate nutritional stores and milk production. Breastfeeding women lose weight faster postpartum than women who bottle feed their infants. Regulating fluid consumption in response to her thirst level will ensure that a breastfeeding woman has adequate hydration without overhydration.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious likely consequence of bladder distention is:

Excessive uterine bleeding. Rationale: Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

Self-care instructions for a woman who has undergone a modified radical mastectomy include that she should:

Expect a decrease in sensation or tingling in her affected arm as her body heals. Rationale: A decrease in sensation and tingling in the affected arm and in the incision are expected for weeks to months after the surgery. Loose clothing should be worn because tight clothing could impede circulation in the affected arm. The axilla of the affected arm should not be shaved nor should depilatory creams or strong deodorants be used. Drains should be emptied at least twice a day, and more often if necessary.

During a health history interview, a woman states that she thinks that she has "bumps" on her labia. She also states that she is not sure how to check herself. The correct response would be to:

Explain the process of vulvar self-examination to the woman and reassure her that she will become familiar with normal and abnormal findings during the examination. Rationale: During assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination. Because the nurse is unsure of the cause of this client's discomfort or the results of examination, any comments about findings or their treatment would be incorrect and inappropriate. The statement in D is not accurate and should not be used in this situation.

A 23-year-old African-American woman is pregnant with her first child. On the basis of the statistics for infant mortality, which plan is most important for the nurse to implement?

Explain to the woman the importance of keeping her prenatal care appointments. Rationale: Nutritional status is an important modifiable risk factor, but it is not the most important action a nurse should take in this situation. The client may need assistance from a social worker at some time during her pregnancy, but this also is not the most important aspect the nurse should address at this time. If the woman has identifiable high-risk problems, her health care may need to be provided by a physician. However, it cannot be assumed that all African-American women have high-risk issues. Additionally, this is not the most important aspect on which the nurse should focus at this time, and it is not appropriate for a nurse to advise or manage the type of care a client is to receive. Consistent prenatal care is the best method of preventing or controlling risk factors associated with infant mortality.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse whether something is wrong. The nurse should respond to this mother's concern by:

Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns. Rationale: The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark green to black color. At this early age this type of stool is typical of both bottle- and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of a meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

A pregnant woman demonstrates understanding of the nurse's instructions regarding relief of leg cramps if she:

Extends her leg and dorsiflexes her foot during the cramp. Rationale: Extending the leg and dorsiflexing the foot are the appropriate relief measure for a leg cramp. Pointing the toes can aggravate rather than relieve the cramp. Application of heat is recommended. Bearing weight on the affected leg can help relieve the leg cramp, so it should not be avoided.

Excessive blood loss after childbirth can have several causes; however, the most common is:

Failure of the uterine muscle to contract firmly. Rationale: Although vaginal or vulvar hematomas, unrepaired lacerations, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention

A nurse providing care to preterm infants should understand that nasogastric and orogastric tubes are used to:

Feed the infants. Rationale: Nasogastric and orogastric tubes are used in gavage feeding, providing breast milk or formula directly to an infant unable to nipple feed. To help maintain body temperature, preterm infants should be placed on warmers. Oxygen, continuous positive airway pressure (CPAP), and a ventilator are used for Oxygen

Which test is performed to determine whether membranes are ruptured?

Fern test Rationale: In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery to determine the presence or absence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is:

Fetal movement palpated by the nurse-midwife. Rationale: Positive signs of pregnancy are those that are attributed to the presence of a fetus, such as hearing the fetal heartbeat and palpating fetal movement. A positive pregnancy test result and Braxton Hicks contractions are probable signs of pregnancy. Quickening is a presumptive sign of pregnancy.

The most common cause of decreased variability in the FHR that lasts 30 minutes or less is:

Fetal sleep cycles. Rationale: A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow results in early decelerations in the FHR, and umbilical cord compression in variable decelerations. Fetal hypoxemia is evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen.

A woman has presented for her preoperative testing appointment. She is scheduled for a myomectomy the following day. As the nurse involved in this woman's care, you understand that this procedure is being performed for:

Fibroids near the outer wall of the uterus that is no larger than a uterus at 12 weeks of gestation. Rationale: If a fibroid tumor lies near the outer wall of the uterus, the uterine size is no larger than at 12 to 14 weeks of gestation, and symptoms are significant, a myomectomy (removal of the tumor) may be performed. This procedure leaves the uterine walls relatively intact, thereby preserving the uterus for future pregnancies. Laser surgery or electrocauterization can be safely used to destroy small fibroids. A hysterectomy (removal of the entire uterus) is the treatment of choice if bleeding is severe or if a fibroid is obstructing normal function of other organs. Bartholin cysts are benign lesions of the vulva; if such a cyst is symptomatic or infected, surgical incision and drainage may provide relief.

Although remarkable developments have occurred in reproductive medicine, assisted reproductive therapies are associated with a number of legal and ethical issues. Nurses can provide accurate information about the risks and benefits of treatment alternatives so couples can make informed decisions about their choice of treatment. Which issue would not need to be addressed by an infertile couple before treatment?

Financial ability to cover the cost of treatment Rationale: Although the method of payment is important, obtaining information about ability to pay is not the nurses' responsibility; it is also of note that 14 states have mandated some form of insurance to assist couples with coverage for infertility. Multiple gestation is indeed a risk of treatment of which the couple needs to be aware. To minimize this risk, generally only three or fewer embryos are transferred. The couple should be informed that there may be a need for multifetal reduction. Nurses can provide anticipatory guidance on disclosure to offspring. Depending on the therapy chosen, there may be a need for donor oocytes, sperm, embryos, or a surrogate mother. Couples who have excess embryos frozen for later transfer must be fully informed before consenting to the procedure. A decision must be made regarding the disposal of embryos in the event of death or divorce or if the couple no longer wants the embryos at a future time.

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:

Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Rationale: Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.

Which of the following would not be included in a labor nurse's plan of care for an expectant mother?

Formulation of the woman's plan of care for labor Rationale: Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment.

Which of the following findings would raise concern for the nurse who is monitoring a postpartum patient who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy?

Fundus midline and firm with spurts of bright red blood upon fundal massage Rationale: Even though the fundus is firm and midline, the fact that spurts of blood are evident on fundal massage may indicate that a tear is present. Further investigation is required as this is considered nonlochial bleeding. Lochia rubra with minimal clots expressed on fundal massage would be considered a normal finding, given that the patient had an SVD of a large infant. Fundus midline and firm with nonpalpable bladder would be considered a normal finding. A report of mild to moderate cramping with a request for pain medication would be considered a normal finding in the postpartum period; the cramping is due to uterine contractions as the uterus returns to its normal prepregnancy status.

A nurse is working in the nursery and observes a nursing student repeatedly performing an Ortolani test. What priority action should the nurse take?

Have the student stop performing the test immediately. Rationale: The Ortolani test should be performed by an experienced practitioner so as to avoid any possible damage. It should not be performed repetitively. Although it would be important to ascertain whether the nursing student knew the clinical implication for the test, the priority safety action would be to intervene and stop further testing.

Parents can facilitate the adjustment of their other children to a new baby by:

Having children at home choose or make a gift to give the new baby on his or her arrival home. Rationale: Because the family is an interactive, open unit, the addition of a new family member affects everyone. Siblings have to assume new positions within the family hierarchy. Parents often face the task of caring for a new child while not neglecting others. Having the siblings choose or make a gift for their new brother or sister is a good way for them to feel included. Parents need to distribute their attention in an equitable manner. One way to ensure that this happens is to set aside special time just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so that she can give her full attention to the other children. Children should be actively involved in the care of the baby, according to their ability, without being overwhelmed.

Which interventions could be implemented by the nurse in the care of a patient who is experiencing altered taste sensation as a result of radiation therapy?

Having her eat chicken or fish in the diet rather than red meat. Having her eat tart foods. rationale: Eating chicken or fish in the diet rather than red meat may help to alleviate altered taste sensation, and eating tart foods may help stimulate the taste buds. Drinking clear liquids and avoiding carbonated liquids are interventions for a patient suffering from nausea and vomiting. Avoiding alcoholic beverages and extreme food temperatures would be interventions for a patient who has stomatitis

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:

Help her breathe into a paper bag. Rationale: This client is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, and circumoral numbness. Notification of the physician is not necessary. The best approach is to have the client breathe into a paper bag held tightly around the nose and mouth to eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available. Slowing the pace of her breathing will not correct the problem, nor will administration of oxygen. Once the pattern of breathing is corrected, her partner can help the woman maintain her breathing rate with visual, tactile, or auditory cues

Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects:

Hematoma formation Rationale: Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation. Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At present she is at the greatest risk for:

Hemorrhage. Rationale: Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention or thrombophlebitis than does a normally implanted placenta.

Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?

Heroin Rationale: The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. Alcohol, PCP, and cocaine are not opiates.

Which statement is most likely to be associated with a breech presentation?

High rate of neuromuscular disorders Rationale: Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus. Breech is the most common malpresentation, affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as the fetal head. Diagnosis is made by abdominal palpation and vaginal examination, and is confirmed by ultrasound.

The two most frequently reported maternal medical risk factors are:

Hypertension associated with pregnancy and diabetes. Rationale: Hypertension and diabetes are the most frequently reported maternal risk factors. Both are associated with obesity. Approximately 20% of U.S. women who give birth are obese. Obesity in pregnancy is associated with the use of more health care services and longer hospital stays. Both drug use and alcohol abuse continue to increase in the maternal population; they are associated with low-birth-weight infants, mental retardation, and birth defects. The number of clients who are homeless or lack health care insurance is increasing; however, these are not the most common risks. Behavior and lifestyle choices do contribute to the health of the mother and fetus.

A nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:

Hypertension. Rationale: Preeclampsia and eclampsia are two noted, deadly forms of hypertension, which is the most common medical complication of pregnancy. A large percentage of pregnant women have nausea and vomiting, but a relative few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:

Hypoglycemia. Rationale: The description is indicative of a macrocosmic infant. Hypoglycemia is common in the infant with macrosomia. The tremors are jitteriness that is associated with hypoglycemia. Other signs of hypoglycemia are apnea, tachypnea, and cyanosis.

The pathology reports indicate that a breast tumor has reached the chest wall. On the basis of this finding, the nurse would interpret the result as which stage?

IIIB Rationale: Stage IIIB indicates that the tumor has direct extension to the chest wall or skin. Stage IV would involve metastasis, and there is no information here to indicate it. Stage I identifies small negative lymph nodes. Stage IIA indicates a tumor with positive nodes.

A pregnant patient who is at term has been informed that her fetus has died. This finding was verified at the physician's office by an ultrasound when the patient stated that she had not felt the baby move for a few days. Subsequently, the patient is going to be admitted to the obstetric unit. When developing a plan of care, the nurse would focus on which priority measure?

Incorporating perinatal palliative care into the patient's plan of care. Rationale: The incorporation of a perinatal palliative care plan would be the priority intervention at this time to help the patient and family members deal with the tragedy of the situation. At this point, a referral to a perinatologist would not be necessary because the determination has already been made that the fetus is dead. Although case management may be included in the plan of care and phone numbers may be provided to the patient regarding funeral arrangements, these actions are not the priority measure.

Which of the following changes are consistent with metabolic function during the postpartum period?

Increased BMR in the immediate postpartum period Secretion of insulinase Decrease in estrogen and cortisol levels Rationale: BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery.

While caring for the newborn, the nurse must be alert for any signs of cold stress. This would include which symptom?

Increased respiratory rate Rationale: In an infant who is cold, the respiratory rate rises in response to the increased need for oxygen. Signs of cold stress include increased activity level and crying (increased basal metabolic rate [BMR] and heat production). A cold infant is at risk for hypoglycemia as the glucose stores are depleted. Newborns are unable to shiver as a means to increase heat production.

Which minerals and vitamins are usually recommended to supplement a pregnant woman's diet?

Iron and folate Rationale: Iron generally should be supplemented, and folic acid supplements often are needed because folate is so important. Fat-soluble vitamins should be supplemented as a medical prescription, as vitamin D might be for lactose-intolerant women. Water-soluble vitamin C sometimes is consumed in excess naturally; vitamin B

Complicated bereavement:

Is an extremely intense grief reaction that persists for a long time. Rationale: Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, abortion can generate complicated emotional responses, and families of lost adolescent pregnancies may have to deal with complicated issues, but these situations are not complicated bereavement.

With regard to the diagnosis and management of amenorrhea, nurses should be aware that:

It may be caused by stress or excessive exercise or both. Rationale: Amenorrhea may be the result of a decrease in follicle-stimulating hormone (FSH) and luteinizing hormone (LH). It is caused usually by stress or low ratio of body fat to lean mass (possibly as a result of excessive exercise), and, in rare occurrences, by a pituitary tumor. Management of stress and eating disorders is usually necessary, including counseling and education about the causes and possible lifestyle changes. In most cases a client needs to decrease her exercise and increase her body weight to resume menstruation. Amenorrhea cannot be treated by medication.

With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:

Its most important function is to afford the opportunity to administer antenatal glucocorticoids. Rationale: Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.

A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician?

Jaundice appeared on the third day of life. Rationale: Physiologic jaundice can be seen in a large percentage of newborns, 60% of term and 80% of preterm, but typically resolves without immediate intervention. The critical factor here is the time of appearance, being within the first 24 hours of life. Jaundice appearing at this time is considered pathological and requires further investigation. The timing in C combined with prematurity also requires further investigation.

The priority assessment in evaluating a pregnant woman with severe nausea and vomiting is:

Ketonuria. Rationale: Determination of ketonuria would be a critical assessment that would lead towards determination of hyperemesis. A pregnant patient with severe nausea and vomiting may have hyperemesis gravidarum and as such requires critical monitoring to determine the nature of the problem. An FBS measurement, although informative, would not be the priority assessment at this time, nor would a bilirubin measurement. A WBC count would indicate the possibility of an infectious source but it would not be a priority assessment in terms of the patient's presentation.

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman 1 day postpartum. An expected finding is:

Little if any change. Rationale: Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.

A patient has been sexually assaulted and presents to the Emergency Department for a sexual assault examination. Which action would be a priority for the nurse assigned to take care of the patient?

Maintain chain of custody for collection of evidence. Rationale: The nurse should place priority on maintaining the chain of custody for the collection of evidence. Because the sexual assault examination is used as part of the evidentiary process when a suspected crime has been committed, the nurse should be mindful not to invalidate physical findings that might affect the course of legal action, such as washing. Psychological referrals may be necessary, but the priority action is to preserve the evidence and assess physical and emotional well-being. Although it is important to obtain information relevant to insurance coverage, this is not the priority action at this time in the context of a sexual assault victim.

If used consistently and correctly, which of the barrier methods of contraception has the lowest failure rate?

Male condoms Rationale: For typical users, the failure rate for male condoms may approach 15%; however, if condoms are used correctly, the failure rate is only 2%. Failure rates are about 29% for spermicides, about 21% for female condoms, and 16% for diaphragms with spermicides.

With regard to protein in the diet of pregnant women, nurses should be aware that:

Many protein-rich foods are also good sources of calcium, iron, and B vitamins. Rationale: Good protein sources such as meat, milk, eggs, and cheese have a lot of calcium and iron. Most women already eat a high-protein diet and do not need to increase their intake. Protein is sufficiently important that specific servings of meat and dairy are recommended. High-protein supplements are not recommended because they have been associated with an increased incidence of preterm births.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to:

Massage her fundus Rationale: A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm.The physician can be called or methylergonovine administered after the fundus massage, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder, so having the woman urinate will not alleviate the problem.

During rounds, a nurse suspects that a patient who has recently delivered via vaginal route is having excessive postpartum bleeding. Which intervention would be the priority action taken by the nurse at this time?

Massage the uterine fundus. Rationale: Massaging of the uterine fundus would be a priority action to help expel clots and stimulate uterine contractions to constrict blood flow. The other actions described, as well as catheterization (if bladder distention is noted) and lochia flow monitoring, may be needed, but none of them is the priority action required at this time.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:

Massage the woman's fundus. Rationale: The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman.

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding?

Mastitis

What is an appropriate indicator for performing a contraction stress test?

Maternal diabetes mellitus and postmaturity Rationale: Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator. Although adolescent pregnancy and poor prenatal care are risk factors for poor fetal outcomes, they are not indicators for performing a contraction stress test. Intrauterine growth restriction is an indicator; history of a previous stillbirth, not preterm labor, is another indicator.

When caring for pregnant women, the nurse should keep in mind that violence during pregnancy:

May be associated with substance abuse by both the pregnant woman and her partner. Rationale: Approximately 8% of pregnant women are battered; the incidence of battering increases during pregnancy. Violence itself has no correlation with the incidence of gestational hypertension. Alcoholism and substance abuse by the woman or her abuser are associated with violence. The rates of violence have actually increased, possibly because of better assessment and reporting mechanisms.

A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease?

Meperidine (Demerol) Rationale: Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol and Nubain are opioid agonist-antagonist analgesics.

Nurses must be cognizant of the growing problem of methamphetamine use during pregnancy. When caring for a woman who uses methamphetamines, it is important for the nurse to be aware of which factor related to the abuse of this substance?

Methamphetamine users are extremely psychologically addicted. Rationale: "Meth" users are extremely psychologically addicted. Typically these women display poor control over their behavior and a low threshold for pain. This substance is relatively inexpensive and easy to obtain. Methamphetamine is a stimulant and a vasoconstrictor. The rate of relapse for methamphetamine users is very high.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by:

Methamphetamines. Rationale: The use of illicit drugs such as cocaine or methamphetamines might cause increased variability. Maternal ingestion of narcotics and tranquilizer use may be the causes of decreased variability. The use of barbiturates may also result in a significant decrease in variability as these drugs are known to cross the placental barrier.

A patient has been prescribed Danazol (Danocrine) therapy for treatment of endometriosis. Which side effect should the patient be monitored for as a part of this ongoing therapy?

Migraine headaches Rationale: Migraine headaches can occur with administration of this medication. Danazol can have masculinizing effects, leading to a decrease in breast size. A decrease in HDL (heart-protective cholesterol) and an increase in LDL occur with this medication, as do weight gain and fluid retention.

Another name for human sex trafficking is:

Modern-day slavery. Rationale: Human sex trafficking has been referred to as "modern-day slavery" according to current literature. It is performed with coercion, and "licensure" does not apply.

In understanding and guiding a woman through her acceptance of pregnancy, a maternity nurse should be aware that:

Mood swings are most likely the result of worries about finances and a changed lifestyle, as well as profound hormonal changes. Rationale: Mood swings are natural and are likely to affect every woman to some degree. A woman may dislike being pregnant, refuse to accept it, and still love and accept the child. Ambivalent feelings about pregnancy are normal for mature or immature women, young or older. Conflicts about desire to perform childrearing and career-related concerns, however, need to be resolved; the baby's arrival ends the pregnancy but not all the issues.

With regard to afterbirth pains, nurses should be aware that these pains are:

More noticeable in births in which the uterus was overdistended. Rationale: A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive:

Moro reflex response Rationale: The characteristics displayed by the infant are associated with a positive Moro reflex response. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open; a characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot; a positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

A patient tells the nurse about the funeral arrangements for her newborn son. The patient is thereby providing the nurse with information about:

Mourning process. Rationale: The mourning process is reflected by traditions and rituals such as the funeral arrangements. The grief process represents the emotional expression of loss. The expression of loss is related to the meaning of perception. Providing information related to funeral arrangements is not an indicator of family reaction.

Which clinical findings would be shared in the presentation of fibrocysts and fibroadenoma?

Moveable Rationale: Both fibrocysts and fibroadenoma are considered to be moveable breast masses. Fibrocysts are multiple lumps, whereas fibroadenoma is a single lump. Fibrocystic masses can be firm or soft, whereas fibroadenomas are firm. Fibrocystic masses may or may not have nipple discharge, whereas fibroadenomas do not.

A client has been prescribed adjuvant tamoxifen therapy. What common side effects might she experience?

Nausea, hot flashes, and vaginal bleeding Rationale: Common side effects of tamoxifen therapy include hot flashes, nausea, vomiting, vaginal bleeding, menstrual irregularities, and rash. The other side effects listed are not commonly seen with this therapy.

Which statement is incorrect regarding bathing of a new baby?

Newborns should be bathed every day, for the bonding as well as the cleaning. Rationale: Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Tub baths may be given as soon as an infant's temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder is not recommended because of the risk of inhalation. Should a parent elect to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply it to the infant.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take?

Notify the primary health care provider immediately. Rationale: To relieve an FHR deceleration the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also, if oxytocin is being infused, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately. Although it is always a good idea to have extra help during any unanticipated obstetric event, calling for help is not the most important nursing measure at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section might be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus.

A patient has been prescribed raloxifene hydrochloride (Evista) for treatment of breast cancer. Which finding, if noted by the nurse prior to medication administration, would lead to immediate contact with the physician?

PMH noted of superficial thrombophlebitis of the left leg. Rationale: A PMH of thrombophlebitis is a significant risk factor for clot formation and stroke with the use of this medication, so the provider should be notified immediately so as to evaluate the clinical indication for this medication type. A slightly decreased red blood cell count would not warrant immediate notification of the provider; the patient should receive follow-up monitoring. Evista is also used as part of a treatment protocol for osteoporosis, so there is no need to notify the provider about this finding. A leukemoid reaction (an increase in white blood cell [WBC] count), is usually self-limiting, and although the provider should be notified, immediate notification is not necessary unless the increase is significant; the nurse should perform further investigation to assess the results of this test.

Which finding would be a source of concern if noted during the assessment of a woman at 12 hours postpartum?

Pain in left calf with dorsiflexion of left foot Rationale: These findings indicate presence of Homans sign, are suggestive of thrombophlebitis, and should be investigated. Postural hypotension is an expected finding related to circulatory changes after birth. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. A temperature of 38° C in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake.

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:

Palpate the uterus and massage it if it is boggy. rationale: The initial management of excessive postpartum bleeding is firm massage of the uterine fundus to stop the bleeding. This is the most important nursing intervention. Then the primary health care provider should be notified or the nurse can delegate this task to another staff member. Administering an oxytocic and ascertaining vital signs are appropriate after assessment has been made and immediate steps have been taken to control the bleeding

Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI?

Paroxetine Rationale: The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly. The absolute risk of any congenital abnormality associated with use of citalopram, fluoxetine, or sertraline is small.

Which indicator would lead the nurse to suspect that a postpartum patient experiencing hemorrhagic shock is getting worse?

Patient complaint of headache and increased reaction time to questioning Rationale: Patient complaint of a headache accompanied by an increased reaction (response) time indicates that cerebral hypoxia is getting worse. Return of blood pressure to normal range would indicate resolving symptoms. Brisk capillary refill is a normal finding. The patient may see "stars" early on in decreased blood flow states.

In which situations would the use of Methergine or prostaglandin be contraindicated even if the patient was experiencing a postpartum significant bleed?

Patient's blood pressure postpartum is 180/90. Patient has a history of asthma. Patient has a mitral valve prolapse. Rationale: Twin pregnancies successfully delivered and grand multiparity are not contraindications to the use of these medications. If a patient is hypertensive or has cardiovascular disease, these medications would not be used. If a patient has a history of asthma, prostaglandin medication would not be used.

When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should:

Perform all examinations and activities under the warmer. Rationale: During all procedures, heat loss must be avoided or minimized for the newborn. All examinations and activities are performed with the infant under the heat panel. The thermistor probe should be placed on the upper abdomen away from the ribs and should be covered with reflective material. Rectal temperature measurements should be avoided because rectal thermometers can perforate the intestine, and the rectal temperature may remain normal until cold stress is advanced.

Which factor would contribute to depletion of weight and metabolic stores in the high risk newborn?

Phototherapy Rationale: The use of phototherapy could lead to insensible heat loss and as a result lead to decreased weight and metabolic stores in the high risk newborn. Frequent breastfeedings and bathing would not have these effects. Maintaining a core temperature would help maintain weight and metabolic stores in the high risk newborn.

A nurse is performing an assessment on a newborn and notes 6 digits on each foot. This finding is an example of:

Polydactyly.

Which test result would provide evidence of fetal blood in maternal circulation?

Positive Kleihauer-Betke test result Rationale: A Kleihauer-Betke test determines the presence of fetal blood in maternal circulation.A positive fern test result would indicate the presence of amniotic fluid, noting that membranes had ruptured. A positive Coombs test result would indicate that the mother has Rh antibodies, and a negative result would indicate no presence of Rh antibodies.

A nurse is monitoring a patient's reflexes (DTRs) while receiving magnesium sulfate therapy for treatment of preeclampsia. Which assessment finding indicates a cause for concern?

Positive clonus response elicited unilaterally Rationale: Positive clonus response elicited unilaterally is a cause for concern as it suggests a hyperactive response. Typically, there is no pain associated with determination of DTRs so this finding would be considered to be normal, as would bilateral DTRs noted at 2+.Even though DTRs at 1+ indicate a sluggish or decreased response, this finding is unchanged since the initiation of therapy. The nurse would continue to monitor.

With regard to preeclampsia and eclampsia, nurses should be aware that:

Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain. Rationale: Vasospasms diminish the diameter of blood vessels, which impedes blood flow to all organs. Preeclampsia occurs after week 20 of gestation and can run the duration of the pregnancy. The causes of preeclampsia and eclampsia are unknown, although several have been suggested. Preeclampsia includes proteinuria; severe cases are characterized by greater proteinuria or any of nine other conditions.

A patient who is pregnant already has Type 2 diabetes with a hemoglobin A1c value of 7. The nurse would categorize this patient as having:

Pregestational diabetes mellitus.

Group B streptococcus (GBS) is part of the normal vaginal flora in 20% to 30% of healthy pregnant women. GBS has been associated with poor pregnancy outcomes and is an important factor in neonatal morbidity and mortality. Which of the following would not be considered to be a risk factor for neonatal GBS infection?

Premature rupture of membranes for longer than 24 hours rationale: Premature rupture of membranes for 18 hours or more increases the risk for neonatal GBS infection.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion?

Prepare the woman for an ultrasound and blood work. Rationale: Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine whether the fetus is alive and within the uterus. Bed rest is recommended for 48 hours initially. D&C is not considered until signs of the progress to inevitable abortion are noted or the contents are expelled and incomplete. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.

With regard to medications, herbs, shots, and other substances normally encountered, the maternity nurse should be aware that during pregnancy:

Prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus. Rationale: The statement in A is especially true for new medications and combinations of drugs. The greatest danger of drug-caused developmental defects exists in the interval from fertilization through the first trimester, when a woman may not realize that she is pregnant. Live-virus vaccines should be part of postpartum care; killed-virus vaccines may be administered during pregnancy. Secondhand smoke is associated with fetal growth restriction and increases in infant mortality.

Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps-Plus is a screening tool designed specifically to identify when there is a need for a more in-depth assessment. Which of the following is not included in the 4 Ps-Plus screening tool?

Present

With regard to primary and secondary powers, the maternity nurse should understand that:

Primary powers are responsible for effacement and dilation of the cervix. Rationale: The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement is generally well ahead of dilation in first-timers; the two are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

Practices such as providing recommended immunizations, infant car seats, and school health education are part of:

Primary preventive care. Rationale: These activities are designed to improve general health and the quality of life, which is the focus of primary preventive care. Mammograms and prostate screening are examples of secondary preventive care. Rehabilitation for a stroke victim is an example of tertiary care. Eliminating the cause of illness beginning in childhood would be in keeping with primordial prevention (i.e., healthy eating and the elimination of fast food to prevent obesity).

A nurse is evaluating several obstetric patients for their risk for cervical insufficiency. Which patient would be considered to be most at risk?

Primip who undergoes a cervical cone biopsy for cervical dysplasia prior to the pregnancy Rationale: Any patient who has had previous surgical interventions (cone biopsy) is at greater risk for cervical insufficiency. There is no indication that a primip is at risk for cervical insufficiency. A grandmultip who has previously had vaginal deliveries without incidence is not necessarily at an increased risk for cervical insufficiency. A multip who has delivered via C section as a result of CPD would not necessarily be at an increased risk as the issue involves pelvic adequacy as determined by pelvic measurements in relationship to the fetus.

The hormone responsible for maturation of mammary gland tissue is:

Progesterone. Rationale: Progesterone causes maturation of the mammary gland tissue, specifically the lobules acinar structures. Estrogen increases the vascularity of the breast tissue.Prolactin is produced after birth and is released from the pituitary gland; it is produced in response to infant suckling and emptying of the breasts. Testosterone has no bearing on breast development.

Which of the following processes or findings increase the risk of preterm infants in which hematologic problems are developing?

Prolonged PT time Decreased red blood cell survival time Decrease in erythropoiesis Rationale: Prolonged PT reflects an increased tendency to bleed in preterm infants. Decrease in red blood cell survival time is seen in such infants. So is decreased functional ability of erythropoietin, which limits red blood cell synthesis. One sees an increase in the size of red blood cells in preterm infants, which affects their survival time. Increased capillary fragility also occurs in preterm infants.

A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. The primary goal of her treatment at this time is to:

Reverse fluid, electrolyte, and acid-base imbalances. Rationale: Fluid, electrolyte, and acid-base imbalances present the greatest immediate danger to the well-being of the mother and fetus and should be corrected as soon as possible. Resting the GI tract and discussing her feelings are components of treatment but are not immediate goals for this client. The ability to retain oral fluid and foods is a longer-term goal of treatment for this condition.

In terms of Rh incompatibility, which situations would cause a potential problem? Select all that apply:

Rh-negative mom having an Rh-positive baby The infant of an Rh-negative mom with Rh-positive father who is homozygous for the trait Rationale: An Rh-negative mom having an Rh-positive baby is the classic presentation for isoimmunization or Rh incompatibility. The infant of an Rh-negative mom with an Rh positive father who is homozygous for the trait would have a potential problem because the infant would be Rh-positive. The other two situations would not cause a problem.

A sexual assault victim is brought into the Emergency Department for triage. Which health care provider should be contacted to perform the assessment?

SANE Rationale: Although the ER doctor may be needed to examine any patient brought into the ED setting, and an RN or LPN can interact with the patient, a sexual assault nurse examiner (SANE), if available, would be the most appropriate choice to care for the patient. A SANE is someone who has been trained and credentialed to care for assault victims.

A 38-year-old woman is screened for breast cancer risk and is found to be at high risk for it. She has no immediate health presentations. Which priority action should be taken as part of her treatment therapy?

Schedule an MRI and mammogram after consultation with her health care provider. Rationale: Because the patient has already been identified as being at high risk, baseline testing with an MRI and mammogram (ultrasound is not indicated) should be established on a yearly basis because of her age. At this time, there is no reason to refer her to a surgeon for discussion of a surgical intervention because she may have an increased lifetime risk of only 20%, and other investigations may be warranted at this time. Although self-breast examination is important, it is not the immediate priority at this time.

Which personal safety precaution should guide the nurse working in home care?

Schedule visits during daylight hours.

A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if:

Seizures do not occur. Rationale: Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. A temporary decrease in blood pressure can occur but is not the purpose of administering this medication. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?

Seldom makes eye contact with her son Rationale: The woman should be encouraged to hold her infant in the en face position and make eye contact with him. Talking and cooing to her son, cuddling, and sharing her son's success at feeding are all normal infant-parent interactions or actions.

Nurses should be aware of the difference that experience can make in labor pain, such as:

Sensory pain for nulliparous women often is greater than for multiparous women during early labor. Rationale: Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be most concerned regarding what this woman consumes during and after tennis matches. Which is the most important?

Several glasses of fluid Rationale: If no medical or obstetric problems contraindicate physical activity, pregnant women should get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise, because dehydration can trigger premature labor. Also the woman's calorie and carbohydrate intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. All pregnant women should consume the necessary amount of protein in their diet, regardless of level of activity. Many pregnant women of this gestation tend to retain fluid, possibly contributing to hypertension and swelling. An adequate fluid intake prior to and after exercise should be sufficient without trying to replace sodium.

Which behavior indicates that a woman is "seeking safe passage" for herself and her infant?

She keeps all prenatal appointments. Rationale: The goal of prenatal care is to foster a safe birth for the infant and mother. Keeping all prenatal appointments is a good indication that the woman is indeed seeking "safe passage." Eating properly, driving carefully, using proper body mechanics, and wearing appropriate footwear during pregnancy are healthy measures that all pregnant women should take.

The nurse advises the woman who wants to have a nurse-midwife provide obstetric care that:

She must be having a low-risk pregnancy. Rationale: Midwives usually see low-risk obstetric clients. Nurse-midwives must refer clients to physicians for complications. Most nurse-midwife births are managed in hospitals or birth centers; a few may be managed in the home. Nurse-midwives may practice with physicians or independently with an arrangement for physician backup. They must refer clients to physicians for complications, but patients are not required to see an obstetrician otherwise. Care in a midwifery model is noninterventional, and the woman and family usually are encouraged to be active participants in the care; this does not imply that medications for pain control are prohibited.

Which factors would lead to an increased likelihood of uterine rupture?

Short interval between pregnancies Patient receiving a trial of labor (TOL) following a VBAC delivery Patient who had a primary caesarean section with a classic incision Rationale: The shorter the interval between pregnancies/deliveries, the higher the risk of uterine rupture. A patient who is having a TOL following a VBAC and a patient who has had a C section with a classic incision into the uterus are at increased risk for uterine rupture. A pregnant woman with a singleton pregnancy (one fetus), even if preterm, is not considered to be at increased risk for uterine rupture; nor is a multipara who has delivered all her infants vaginally.

Postbirth uterine/vaginal discharge, called lochia:

Should smell like normal menstrual flow unless an infection is present. Rationale: An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia is usually seen after cesarean births. It usually increases with ambulation and breastfeeding.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period?

Skin-to-skin contact of mother and baby should be encouraged. Rationale: The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. Although complete assessment in the nursery is the practice in many facilities, it is neither evidence-based nor supportive of family-centered care. Handing the mother the blanket-wrapped baby is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed on the mother skin to skin. The father or support person is likely also anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin with the mother and breastfeeding has been initiated.

A couple presents for their first appointment at an infertility center. A noninvasive test done during initial diagnostic testing is:

Sperm analysis Rationale: Sperm analysis, the basic test for male infertility, is the only noninvasive procedure listed. A hysterosalpingogram is radiographic film examination that allows visualization of the uterine cavity after instillation of radiopaque contrast medium through the cervix. During an endometrial biopsy, a small cannula is introduced into the uterus and a portion of the endometrium is removed for histologic examination. Laparoscopy is useful in order to view the pelvic structures intraperitoneally.

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased?

Squatting Rationale: Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. Sitting may assist with fetal descent, but like a semirecumbent or side-lying position, it does not increase the size of the pelvic outlet.

An essential component of counseling women regarding safe sex practices is discussion about avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) is the condom. Nurses can help motivate clients to use condoms by initiating a discussion related to a number of aspects of condom use. The most important of these is:

Strategies to enhance condom use. Rationale: When the nurse opens discussion on safe sex practices, the woman is given permission to clear up any concerns or misapprehensions she may have regarding condom use. The nurse can also suggest ways that the woman can enhance her condom negotiation and communications skills, such as role-playing, rehearsal, cultural barriers, and situations that put the client at risk. Although women can be taught the differences among condoms (such as size ranges, where to purchase, and price), this issue is not as important as negotiating the use of safe sex practices. Women must address the issue of condom use with every sexual contact. Some men need time to think about using condoms; if a man appears reluctant, the woman may want to reconsider the relationship. Although not ideal, women may safely carry condoms in shoes, wallets, or inside their bras. They should be taught to keep condoms away from heat. This information is important but is not germane if the woman cannot even discuss strategies on how to enhance condom use.

A pregnant woman who is at 21 weeks of gestation has an elevated blood pressure of 140/98. Past medical history reveals that the woman has been treated for hypertension. On the basis of this information, the nurse would classify this patient as having:

Superimposed preeclampsia. Rationale: Because this patient already has a medical history of hypertension and is now exhibiting hypertension prior after the 20th week of gestation, she would be considered to have superimposed pre-eclampsia. Pre-eclampsia would be the classification in a patient without a history of hypertension who was hypertensive following the 20th week of pregnancy. Gestational hypertension occurs after the 20th week of pregnancy in a patient who was previously normotensive. Even though the patient has chronic hypertension, the fact that she is now pregnant determines that she would be classified as having superimposed pre-eclampsia.

A woman taking an oral contraceptive pill (OCP) as her birth control method of choice should notify her health care provider immediately if she notes:

Swelling and pain in one of her legs Rationale: Leg pain and swelling (edema) may indicate thrombophlebitis and should be reported immediately. Breast tenderness and weight gain are expected side effects of OCPs, and mood swings are a common side effect.

Which of these medications would be classified as a Category X substance that is not to be used during pregnancy?

Temazepam (Restoril) Rationale: Restoril is classified as a Category X drug and is contraindicated during pregnancy on the basis of clinical studies. Ativan, Xanax, and Librium are classified as Category D drugs and as such would not be given during pregnancy unless a benefits to risks ratio was established.

Providing treatment and rehabilitation for people who have developed disease is part of:

Tertiary preventive care. Rationale: Primary preventive care involves promoting healthy lifestyles. Secondary preventive care involves targeting populations at risk. Tertiary preventive care is the treatment or rehabilitation of those who already have a specific disease.

Concerning the third stage of labor, nurses should be aware that:

The duration of the third stage may be as short as 3 to 5 minutes. Rationale: The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage; the risk of hemorrhage increases as the length of the third stage increases.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that:

The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. Rationale: In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second-stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

With regard to the father's acceptance of the pregnancy and preparation for childbirth, the maternity nurse should know that:

The father goes through three phases of acceptance of his own. Rationale: A father typically goes through three phases of acceptance: accepting the biologic fact, adjusting to the reality, and focusing on his role. Typically, the expectant father's ambivalence ends by the first trimester, and he progresses to adjusting to the reality of the situation and focusing on his role. The father-child attachment can be as strong as the mother-child relationship and can begin during pregnancy. In the last 2 months of pregnancy, many expectant fathers work hard to improve the environment of the home for the child.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. The nurse concludes that:

The placenta has separated. Rationale: Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

Fetal well-being during labor is assessed by:

The response of the fetal heart rate (FHR) to uterine contractions (UCs). Rationale: Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Although FHR accelerations and an FHR greater than 110 beats/min may be reassuring, they are only two components of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

With regard to umbilical cord care, nurses should be aware that:

The stump can easily become infected. Rationale: The cord stump is an excellent medium for bacterial growth. If bleeding occurs, the nurse should first check the clamp (or tie) and apply a second one; if the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

What information will the nurse include in planning for the care of a woman who has had a vaginal hysterectomy?

The woman should expect no changes in her hormone levels. rationale: Unless the ovaries also were removed (in which case surgical menopause occurs), hormonal levels should not change. Menses will cease, but the hypothalamic-pituitary-ovarian axis remains intact. The client should avoid tub baths, intercourse, and douching until after the follow-up exam. The woman should expect to have vaginal discharge for 4 to 6 weeks. Full recovery varies from woman to woman, depending on risk factors and individual healing.

Which is correct concerning the performance of a Papanicolaou (Pap) test?

The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test. Rationale: Women should not douche, use vaginal medications, or have sexual intercourse for 24 hours before a Pap smear specimen is collected so as not to alter the cytology results. Also, only warm water should be used on the speculum so as not to alter the cytology results. The cytologic specimen should be obtained first. Pap tests are performed annually for sexually active women or by age 18, especially if risk factors for cervical cancer or reproductive tract infections are present. Pap tests may be performed every 3 years in low-risk women after three negative results on consecutive annual examinations.

A woman presents to the emergency department complaining of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary health care provider finds that the cervix is closed. The anticipated plan of care for this woman is based on a probable diagnosis of which type of spontaneous abortion?

Threatened Rationale: A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. Heavy bleeding, mild to severe cramping, and cervical dilation are the presentation for both incomplete abortion and inevitable abortion. A woman with a septic abortion presents with malodorous bleeding and, typically, a dilated cervix.

A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time?

Transvaginal ultrasound Rationale: An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women, whose thick abdominal layers cannot be penetrated adequately with the abdominal approach. A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal).

Which statement about multifetal pregnancy is not accurate?

Twin pregnancies come to term with the same frequency as single pregnancies. Rationale: Twin pregnancies often end in prematurity; serious efforts should be made to bring the pregnancy to term. A woman with a multifetal pregnancy often experiences anemia because of the increased demands of two fetuses; this issue should be monitored closely throughout her pregnancy. The client may need nutrition counseling to ensure that she gains more weight than what is needed for a singleton birth. The considerable uterine distention in multifetal pregnancy is likely to cause backache and leg varicosities; maternal support hose should be recommended.

Which of the following statements about the prevalence of perinatal mental health problems is true?

Up to a ¼ of pregnant women will experience some aspect of depression during their pregnancies. Income status plays a significant role in the presentation of perinatal mental health problems. Between 30 and 50 billion dollars accounts for productivity and direct medical costs related to depression in women. Rationale: The WHO recognizes depression as the leading cause of disability in women. Between 14% and 23% of women will experience some aspect of depression during their pregnancies. Low income plays a significant factor in the presentation of perinatal mental health problems. Higher incidence of PPD is found in about 25% of women. The economic costs related to depression treatment in women are extremely high, ranging between 30 and 50 billion dollars.

Your client has just returned from a uterine artery embolization (UAE) procedure. Prior to her discharge it is very important to discuss symptoms that require a call to the health care provider. Which of the following would not require contacting the physician?

Urinary frequency Rationale: The physician should be notified if the client is experiencing urinary retention, but urinary frequency is not a complication of UAE. Fever of 39° C or greater may indicate an infection, and the physician should be notified. A slight fever or pain may be experienced as a result of acute fibroid degradations. Swelling or hematoma at the puncture site may be an indication of bleeding into the groin. The client should not experience any abnormal vaginal discharge (foul odor, brown color, or tissue).

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:

Uses the peribottle to rinse upward into her vagina. Rationale: The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash the vulva and perineum is an appropriate measure. Washing from the symphysis pubis back to the episiotomy is an appropriate infection control measure. The client should be instructed to change her perineal pad every 2 to 3 hours.

While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically:

Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. Rationale: One week after birth the woman should exhibit behaviors characteristic of the dependent-independent or taking-hold stage. She still has needs for nurturing and acceptance by others. Wanting to discuss the events of her labor and delivery are characteristics of the taking-in stage, as are a limited readiness to learn and reduced attention span; this stage lasts from the first 24 hours until 2 days after delivery. Having reestablished her role as a spouse reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is:

Ventricular septal defect (VSD). Rationale: VSD with increased pulmonary blood flow is the most common type of heart defect, with a prevalence of 27 per 10,000 births, and accounts for about 30% to 35% of all congenital heart defects. Tetralogy of Fallot has an incidence of 4.7 per 10,000 births and is the most common cardiac defect with decreased blood flow. Pulmonary stenosis, a defect that causes obstruction to blood flow out of the heart, is less common. Transposition of the great vessels is a complex cardiac anomaly that involves a flow of mixed saturated and desaturated blood in the heart or great vessels.

Fetal bradycardia is most common during:

Viral infection. Rationale: Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, viral infections such as cytomegalovirus (CMV), maternal hypothermia, and maternal hypothermia. Maternal hyperthyroidism, fetal anemia, and tocolytic treatment using ritodrine will most likely result in fetal tachycardia.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is:

Vision. Rationale: The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

Which statement regarding infant weaning is correct?

Weaning can be mother or infant initiated. Rationale: Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. In mother-led weaning, the mother decides which feedings to drop. Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants younger than 6 months. If the infant is weaned prior to 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning.

The breasts of a woman who is bottle feeding her baby are engorged. The nurse should instruct her to:

Wear a snug, supportive bra. Rationale: A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners would keep the nipples and areola moist, leading to excoriation and cracking.

When weighing a newborn, the nurse should:

Weigh the newborn at the same time each day for accuracy. Rationale: Weighing a newborn at the same time each day allows for the most accurate weight. The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety.

Which statements are true regarding the occurrence of obesity in the United States?

Women in the age group 40 to 59 years have the highest prevalence. Obesity is associated with hypercholesterolemia. Women who are obese may be more likely to have irregularities of the menstrual cycle.

The recommended treatment to prevent transmission of human immunodeficiency virus (HIV) to the fetus during pregnancy is:

Zidovudine Rationale: Perinatal transmission of HIV has decreased significantly in the past decade as a result of prophylactic administration of the antiretroviral drug zidovudine to pregnant women in the prenatal and perinatal periods. Acyclovir is an antiviral treatment for herpes simplex virus (HSV). Ofloxacin is an antibacterial treatment for gonorrhea. Podophyllin is a solution used in the treatment of human papillomavirus.

The most appropriate statement that the nurse can make to bereaved parents is:

"I'm sorry." Rationale: One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment, such as, "I'm sorry." The initial impulse may be to reduce one's sense of helplessness and to say or do something that you think will reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. The statement in C is not a therapeutic response for the nurse to make.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is:

"It's normal to be anxious about labor. Let's discuss what makes you afraid." Rationale: This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool. The statement in A negates the woman's fears and is not therapeutic. The statement in C also negates the woman's fears and offers a false sense of security. The statement in D is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

A married couple is discussing male and female sterilization with the nurse. Which statement is most appropriate for the nurse to make?

"Major complications after sterilization are rare." Rationale: Sterilization procedures can be safely done on an outpatient basis. Complications are uncommon and usually not serious. The average failure rate for female sterilization is 0.5% and for male sterilization is 0.15%. A vasectomy has no effect on potency or volume of ejaculate. Sterilization reversal is costly, difficult, and uncertain.

What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

"My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." Rationale: This is an accurate statement and indicates her understanding of her expected menstrual activity. The woman can expect her first menstrual cycle, which occurs by 3 months after childbirth, to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.

A male client asks the nurse why it is better to purchase condoms that are not lubricated with nonoxynol-9 (a common spermicide). The nurse's most appropriate response is:

"Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; also, it has been linked to an increase in the transmission of human immunodeficiency virus (HIV) and can cause genital lesions." Rationale: Answer B is a true statement. Nonoxynol-9 may cause vaginal irritation.It has no effect on the quality of sexual activity or on penile sensitivity.

A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates her understanding of the instructions when the woman states:

"True labor contractions will continue and get stronger even if I relax and take a shower." Rationale: True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions stop with walking or a change of position.

A pregnant woman at 10 weeks of gestation jogs three or four times per week. She is concerned about the effect of exercise on the fetus. The nurse should tell her:

"You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month." Rationale: The nurse should inform the woman that she may need to reduce her exercise level as the pregnancy progresses. Typically, running should be replaced with walking around the seventh month of pregnancy. Physical activity promotes a feeling of well-being in pregnant women. It improves circulation, promotes relaxation and rest, and counteracts boredom. Simple measures should be initiated to prevent injuries, such as warm-up and stretching exercises, to prepare the joints for more strenuous exercise.

A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is the most appropriate for instructing the woman about which herbal preparations to avoid while trying to conceive?

"You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to conceive." Rationale: Although most herbal remedies have not been proven clinically to promote fertility, herbs that a woman should avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. Nettle leaf, dong quai, and vitamin E promote fertility; calcium and magnesium may promote fertility and conception.

A woman is using the basal body temperature (BBT) method of contraception. She calls the clinic and tells the nurse, "My period is due in a few days, and my temperature has not gone up." The nurse's most appropriate response is:

"You probably didn't ovulate during this cycle." Rationale: Pregnancy cannot occur without ovulation (which is being measured using the BBT method). The absence of a temperature decrease most likely is the result of lack of ovulation. Illness would most likely cause an increase in BBT. A comment such as the one in B discredits the client's concerns.

The perinatal continuum of care begins with:

Family planning and preconception care. Rationale: The continuum of care begins with family planning and preconception care, not at the beginning of pregnancy.

Baby-friendly hospitals mandate that infants be put to breast within the first __ after birth.

1 hour Rationale: Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the BFHI mandates 1 hour. Four hours is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity according to the GTPAL system?

3-1-0-1-0

Which hematocrit (HCT) and hemoglobin (HGB) results represent the lowest acceptable values for a woman in the third trimester of pregnancy?

33% HCT; 11 g/dL HGB Rationale: 38% HCT; 14 g/dL HGB and 35% HCT; 13 g/dL HGB are within normal limits in a nonpregnant woman. 33% HCT; 11 g/dL HGB represents the lowest acceptable values during the first and the third trimesters, and 32% HCT; 10.5 g/dl HGB represents the lowest acceptable values for the second trimester, when the hemodilution effect of blood volume expansion is at its peak.

Which ratio would be used to restore effective circulating volume in a postpartum patient who is experiencing hypovolemic shock?

3:1 Rationale: A 3:1 ratio, of 3 ml fluid infused for every 1 ml of estimated blood loss, is recommended to restore circulating volume.

In most healthy newborns, blood glucose levels stabilize at __ mg/dL during the first hours after birth:

50 to 60 Rationale: In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first several hours after birth. 80 to 100 mg/dL is the normal plasma glucose level in the adult. A blood glucose level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. An infant with this level can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life the blood glucose levels should be approximately 60 to 70 mg/dL.

A Native-American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for bottle feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of:

A belief that babies should not be fed colostrum. Rationale: Delayed attachment is a developmental concern, not a cultural belief. Embarrassment is likely not the cause for a delay in the initiation of breastfeeding and should be explored further by the nurse. The mother may voice her disappointment that the infant is a girl; however, this would rarely cause her to delay breastfeeding and would manifest itself in other ways. Native Americans commonly use cradleboards and avoid handling their newborns often. They also believe that infants should not be fed colostrum.

Which of the following could affect female fertility?

A clinical diagnosis of anemia Bicornate uterus Uterine abnormality Rationale: A diagnosis of anemia and the presence of a uterine abnormality can both affect a woman's fertility status. Partner relationship status, although important in one's well-being, does not typically affect female fertility, and financial history is not a factor.The presence of CPD relates to whether or not a woman can successfully deliver a baby vaginally on the basis of obtained pelvic measurements.

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume that generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct?

A common practice among Mexican women is known as las dos cosas.

Which sign does not precede the onset of labor?

A decline in energy, as the body stores up for labor Rationale: A surge of energy is a phenomenon that is common in the days preceding labor. After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Prior to the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength; bloody show may be passed.

With regard to spinal and epidural (block) anesthesia, nurses should know that:

A high incidence of postbirth headache is seen with spinal blocks. Rationale: The headaches may be prevented or mitigated to some degree by a number of methods. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for a spinal headache. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

Concerning congenital abnormalities involving the central nervous system, nurses should be aware that:

A major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. Rationale: The nurse protects the infant by laying the baby on his or her side. Most congenital anomalies have had a stable neonatal death rate since the 1930s; rates of NTDs are declining because of mandatory fortification of foods with folic acid. Spina bifida occulta often is asymptomatic; spina bifida cystica has a visible sac.

Which of the following actions, if demonstrated by a nursing student, could lead to dismissal from the health program?

A nursing student posts pictures of clinical site experiences on her Facebook page. Student nurses share their thoughts about their clinical site experiences on Twitter. Rationale: Although a nursing student can provide a phone number to a patient so that they remain in touch, the student should be aware of the limits of the relationship while in nursing school. Nursing students going out to lunch following a clinical experience while in uniform would not pose a problem as long as they maintained their professional demeanor and did not discuss clinical events. Posting of images related to clinical experiences on a Facebook page would make the student liable for violation of privacy. Sharing of thoughts related to clinical experiences on social media may result in dismissal from a health program if a student nurse provides information that results in violation of the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule.

Which statement is accurate regarding the ABO blood typing system in the body?

A person with type O blood has antibodies to type A and type B. Rationale: A person with type O blood has antibodies to both type A and type B, but no antigens. With type AB blood, you do not have antibodies.

Which woman has the highest risk for endometrial cancer?

A postmenopausal woman with hypertension Rationale: Endometrial cancer is most often seen in postmenopausal women between the ages of 50 and 65. Hypertension is a risk factor associated with the development of this malignancy. The use of an intrauterine device (IUD) does not increase a woman's risk for endometrial cancer. Birth control might offer some protection. The development of a cystocele will not increase a woman's risk for endometrial cancer.

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:

A respiratory rate of 10 breaths/min. Rationale: A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2+ are a normal finding, as is absence of ankle clonus.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?

Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Rationale: The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official lull phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

A woman is diagnosed with having a stillborn. At first she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called:

Acute distress.

Which of the following statements is not used to describe a characteristic of a uterine contraction?

Appearance (shape and height) Rationale: Uterine contractions are described in terms of frequency, intensity, duration, and resting tone.

Which factors predispose an infant to birth injuries?

Application of an internal fetal scalp electrode Vacuum-assisted birth Rationale: The use of an internal fetal scalp electrode could result in a scalp injury, which would be evident upon birth. The use of vacuum extraction could lead to a birth injury. Very young age (less than 16) and older age (more than 35) in a primipara are more likely to predispose an infant to birth injuries. Vertex presentation is a normal finding and as such would not typically lead to a birth injury.

During pregnancy, alcohol withdrawal may be treated using:

Benzodiazepines. Rationale: Symptoms that occur during alcohol withdrawal can be managed with short-acting barbiturates or benzodiazepines. Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids and aminophylline are not used to treat alcohol withdrawal.

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:

Breathing in a respiratory pattern common to premature infants. Rationale: The pattern of 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of rapid respiration is called

The nurse is providing discharge instructions related to the baby's respiratory system. Which statement should not be included as part of discharge teaching?

Don't let the infant sleep on his or her back. Rationale: The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections, so infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and furniture that can trap them.

The viral sexually transmitted infection (STI) that affects most people in the United States today is:

Human papillomavirus (HPV) rationale: HPV infection is the most prevalent viral STI seen in ambulatory health care settings.

Which suggestion about weight gain is not an accurate recommendation?

In twin gestations, the weight gain recommended for a single fetus pregnancy should simply be doubled. Rationale: Women bearing twins need to gain more weight (usually 16 to 20 kg) but not necessarily twice as much. Underweight women need to gain the most. Obese women need to gain weight during pregnancy to equal the weight of the products of conception. Adolescents are still growing; therefore, their bodies naturally compete for nutrients with the fetus.

An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe for the baby. The nurse should tell the couple that:

Intercourse and orgasm are often contraindicated if a history or signs of preterm labor are present. Rationale: Uterine contractions that accompany orgasm can stimulate labor and would be problematic if the woman were at risk for or had a history of preterm labor. Some spotting can normally occur as a result of the increased fragility and vascularity of the cervix and vagina during pregnancy. Intercourse can continue as long as the pregnancy is progressing normally. Safer-sex practices are always recommended; rupture of the membranes may require abstaining from intercourse.

Which statement is true with regard to premenstrual dysphoric disorder (PMDD)?

It can manifest symptoms similar to those of panic disorders. Rationale: PMDD is a variant of PMD and includes psychologic presentations as well as physical presentations. It is classified as a psychologic disorder. The patient may experience panic attacks. Symptom presentation becomes chronic, recurrent, and cyclical in nature. Physical symptoms occur with PMDD (physical and mood changes) and are present at the start of the disorder. A symptom-free period in the follicular phase of the menstrual cycle is seen in PMD, not PMDD.

Which statement is inaccurate with regard to normal labor?

It is completed within 8 hours. Rationale: Although the amount of time varies with each woman, a normal uncomplicated labor is usually completed within 18 hours. In normal labor, a single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent is the trajectory that the nurse expects for a woman experiencing a normal labor, which usually occurs with no complications.

With regard to dysfunctional uterine bleeding (DUB), the nurse should be aware that:

It is most commonly caused by anovulation. Rationale: Anovulation may occur because of hypothalamic dysfunction or polycystic ovary syndrome. DUB most often occurs when the menstrual cycle is being established or when it draws to a close at menopause. A diagnosis of DUB is made only after all other causes of abnormal menstrual bleeding have been ruled out. The most effective medical treatment is oral or intravenous estrogen.

Which statement is true about the term contraceptive failure rate?

It varies from couple to couple, depending on the method and the users. Rationale: The contraceptive failure rate is strictly a statistical measure of likely accidental pregnancy over a couple's first year of use. Failure rates decline over time because users gain experience. Contraceptive effectiveness varies from couple to couple, depending on how well a contraceptive method is used and how well it suits the couple.

If a woman complains of back labor pain, the nurse might best suggest that she:

Lean over a birth ball with her knees on the floor. Rationale: The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged. Deep cleansing breaths will assist with any labor pain; however, it is very important that this woman's position is changed so that she is not on her back.

Which action of a breastfeeding mother indicates the need for further instruction?

Leans forward to bring breast toward the baby. Rationale: To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. The other actions described are correct.

Which TORCH infection could be contracted by the infant because the mother owned a cat?

Toxoplasmosis

The nurse's best measure when evaluating the care of a woman in an abusive situation is based on the:

Woman's declaration of a safety plan. Rationale: Safety is the most significant part of the intervention. A decision to leave the partner would be a positive step for the woman, but it is not the most significant part of the intervention. In addition, many women choose to return to the relationship. The woman may express her gratitude to the nurse in an effort to end the conversation; this does not indicate the woman's readiness to leave the relationship or to make a plan for safety. Couples counseling generally is not recommended. Initially, individual counseling would be more beneficial. Neither would be a measure of success in the evaluation of the care plan of an abused woman.

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that:

If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. Rationale: If the ganglia are disconnected completely from the spinal cord, the damage is permanent.

The nurse understands the importance of a walking survey because this tool:

Is a method of observing the resources and health-related environment of the community. Rationale: A walking survey is a valuable tool that has nothing to do with exercise. It is an observational method conducted by nurses in a community to assess the health environment of the community.

A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know whether it is safe for her to have a drink with dinner now. The nurse tells her:

"Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy." Rationale: Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised. A safe level of alcohol consumption during pregnancy has not yet been established. The first trimester is a crucial period of fetal development, but pregnant women at all gestations are counseled to eliminate all alcohol from their diet.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" The nurse's best response to this woman is:

"I can understand your need to find an answer to what caused this. What else are you thinking about?" Rationale: The statement in D is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. Trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feelings does not help the process of grief. Additionally the response in B probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories, and listening with care, which silence would not do.

What symptom described by a woman is characteristic of premenstrual syndrome (PMS)?

"I feel irritable and moody a week before my period is supposed to start." Rationale: PMS is a cluster of physical, psychological, and behavioral symptoms, including nausea and headaches, that begin in the luteal phase of the menstrual cycle and resolve within a couple of days of the onset of menses. Abdominal bloating and breast pain are likely to occur a few days prior to menses, not after it has begun as described in statement D.

A nursing student is reviewing information relative to cultural beliefs about infertility. Which statement, if made by a patient, would require intervention?

"I have to take full responsibility for my failure to conceive." Rationale: In certain cultures, women are viewed as being responsible for all fertility problems, but the fact that this statement acknowledges complete fault would require the nursing student to intervene in order to provide compassion and decrease the psychologic stress of the patient. Statements about consulting the partner are expected, because both partners should discuss and explore available fertility options. Consultation about infertility treatments with a spiritual leader, regardless of religion, requires no intervention. Certain religions, such as Roman Catholicism, do not allow IVF therapy.

The nurse-midwife is teaching a group of women who are pregnant about Kegel exercises. Which statement by a participant would indicate a correct understanding of the instruction?

"I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises." Rationale: Guidelines suggest that women perform between 30 and 80 Kegel exercises daily. The correct technique is to hold the contraction for at least 10 seconds and to rest for 10 seconds in between so the muscles can have time to recover and each contraction can be as strong as the woman can make it. The exercises are best performed in a supine position with the knees bent. Kegel exercises should be performed throughout the pregnancy to achieve the best results.

An expectant father confides in the nurse that his pregnant wife, at 10 weeks of gestation, is driving him crazy. "One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?" The nurse's best response is:

"This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant." Rationale: The statement in C is the most appropriate response because it gives an explanation and a time frame for when the mood swings may stop. The statement in A is an appropriate response but it does not answer the father's question. Mood swings are a normal finding in the first trimester; the woman does not need counseling. The statement in D is judgmental and not appropriate.

Which statements would not be advisable to use as a basis for therapeutic discussion following a perinatal loss?

"This must be hard for you" "I'm sorry" "I am sad for you" Rationale: "This must be hard for you," "I'm sorry," and "I am sad for you" are acceptable statements following perinatal loss. "You're young, you can have other children" and "You wanted a boy anyway, so now you have another chance" would not be considered therapeutic.

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test?

"This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." Rationale: The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements. An ultrasound requires a full bladder. An amniocentesis is the test after which a pregnant woman should be driven home. A maternal serum alpha-fetoprotein test is used in conjunction with unconjugated estriol levels and human chorionic gonadotropin helps to detect Down syndrome

Which of the following is the most common kind of placental adherence seen in pregnant women?

Accreta Rationale: Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Placenta increta leads to deep penetration of the myometrium.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:

Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. Rationale: Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident with growth, the mental capacities never become normal.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver:

Alerts the physician that the infant has a dislocated hip. Rationale: The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. The statement in B is inappropriate and may result in unnecessary anxiety for the new parents.

Sexual assault is:

An act of force in which an unwanted and uncomfortable sexual act occurs.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae:

Are benign if they disappear within 48 hours of birth. Rationale: Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. They usually occur with a breech presentation vaginal birth, although in this case they are soft-tissue injury resulting from the nuchal cord at birth. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae may also result from decreased platelet formation.

The nurse providing care for the laboring woman understands that accelerations with fetal movement:

Are reassuring. Rationale: Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being; they do not warrant close observation. Umbilical cord compression results in variable decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the FHR.

The 5 As screening intervention tool is used to implement smoking cessation strategies on the basis of patient response. What do the 5 As stand for?

Ask, assess, advise, assist, and arrange follow-up Rationale: The 5 As stand for ask, assess, advise, assist, and arrange follow-up.

When would the best timeframe be to establish gestational age based on ultrasound?

Between 14 and 22 weeks Rationale: Ultrasound determination of gestational age dating is best done between 14 and 22 weeks. It is less reliable after that period because of variability in fetal size. Standard sets of measurements relative to gestational age are noted around 10 to after 12 weeks and include crown-rump length (after 10), biparietal diameter (after 12), femur length, and head and abdominal circumferences.

Which of the following findings would be a cause for concern for a nurse who is monitoring an obstetric patient who is in early labor?

Biparietal diameter of less than 9.25 cm Transverse lie Android pelvis Rationale: A biparietal diameter at term is typically noted as 9.25 cm, and the finding of a smaller measurement would cause a concern related to the mode of delivery. A transverse lie would also cause a concern relative to the mode of delivery because a cesarean section would be indicated. An android pelvis would cause a concern related to the mode of delivery. A vertex presenting part and a general flexion attitude are normal findings and would not cause concern.

The process in which the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics is called:

Bonding Rationale: Bonding is the process through which over time parents form an emotional attachment to their infant.

With regard to nutritional needs during lactation, a maternity nurse should be aware that:

Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful. Rationale: A lactating woman needs to avoid consuming too much caffeine. Vitamin C, zinc, and protein levels need to be moderately higher during lactation than during pregnancy. The recommendations for iron and folic acid are somewhat lower during lactation. Lactating women should consume about 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.

A woman was treated recently for toxic shock syndrome (TSS). She has intercourse occasionally and uses over-the-counter protection. On the basis of her history, what contraceptive method should she and her partner avoid?

Cervical cap Rationale: Women with a history of TSS should not use a cervical cap. Condoms, vaginal film, and vaginal sheaths are not contraindicated for a woman with a history of TSS.

Where do most deliveries for pregnant women who have mental health issues take place?

Community hospital settings Rationale: Unless there is some specific psychiatric mental health issue that requires that a patient remain in a locked unit, most pregnant women who have mental health issues deliver in community settings. Although midwives are trained to provide obstetric care, they typically do not take care of complex patients, and a woman who had a diagnosed mental health issue would be classified as a complex patient.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use:

Counterpressure against the sacrum.

A patient has been sexually assaulted and is receiving an initial evaluation in the Emergency Department. She is concerned that she may become pregnant. Which priority action should the nurse implement so as to address the patient's concern?

Determine the length of time after assault, and if it is less than 120 hours, emergency contraception may be provided. Rationale: It would be most important for the nurse to determine when the assault occurred so as to interpret this information relative to the pregnancy test results. Even if results of a pregnancy test are negative, the patient may still be pregnant, and further evaluation should be performed. Although the nurse may want to ask about the LMP, it will not provide evidence about whether or not the patient may be pregnant. A D&C may prove to be needed but not at this time.

A group of fetal monitoring experts (National Institute of Child Health and Human Development, 2008) recommends that fetal heart rate (FHR) tracings demonstrate certain characteristics to be described as reassuring or normal (category I). These characteristics include:

Early decelerations, either present or absent. Rationale: Early decelerations, the absence of late decelerations, and the presence of accelerations indicate a normal category I tracing. Bradycardia not accompanied by variability is a category II tracing, as is fetal tachycardia. A sinusoidal pattern is considered an ominous sign and is definitely an abnormal category III tracing.

Which of the following conditions has not contributed to an increase in maternity-related health care costs?

Early postpartum discharges Rationale: Early postpartum discharges are associated with decreased health care costs. High-risk factors and high-tech equipment both increase such costs. Clinical evidence indicates that maternity-related health care costs are increased for LBW and high-risk infants.

A pregnant woman experiencing nausea and vomiting should:

Eat small, frequent meals (every 2 to 3 hours). Rationale: Eating small, frequent meals is a correct suggestion for a pregnant woman experiencing nausea and vomiting. She should avoid consuming fluids early in the day or when nauseated, but should compensate by drinking fluids at other times. She should also reduce her intake of fried foods and other fatty foods.

In the current practice of childbirth preparation, emphasis is placed on:

Encouraging expectant parents to attend childbirth preparation in any or no specific method. Rationale: Encouraging expectant parents to attend class is most important, because preparation increases a woman's confidence and thus her ability to cope with labor and birth. The goal is to encourage new parents to attend any one of the acceptable childbirth education programs. Gaining in popularity are

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:

Encouraging the woman to try various upright positions, including squatting and standing. Rationale: Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. An epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

A mother's household consists of her husband, his mother, and another child. She is living in a/an:

Extended family.

Fetal circulation can be affected by many factors during labor. Accurate assessment of the laboring woman and fetus requires knowledge of these expected adaptations. Which factor will not affect fetal circulation during labor?

Fetal position Rationale: Maternal position may affect fetal circulation; however, fetal position is unlikely to disturb umbilical blood flow. Uterine contractions during labor tend to decrease circulation and subsequent perfusion. Most healthy fetuses are well able to compensate for this stress and exposure to increased pressure while moving passively through the birth canal during labor. Maternal blood pressure is likely to have a significant effect on fetal circulation. Compression of the cord and reduction of umbilical blood flow do affect fetal circulation.

Which statement about genital herpes is inaccurate?

Genital herpes is also known as genital warts. Rationale: Genital warts are one of the most common sexually transmitted infections (STIs); however, it is also known as human papillomavirus (HPV),

In the past, factors to determine whether a woman was likely to have a high risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high risk pregnancy has been adopted. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category?

Geographic

Which presumptive sign (felt by woman) or probable sign (observed by the examiner) of pregnancy is not matched with another possible cause(s)?

Goodell sign—cervical polyps Rationale: Goodell sign might be the result of pelvic congestion, not polyps. Amenorrhea sometimes can be caused by stress, vigorous exercise, early menopause, or endocrine problems. Quickening can be gas or peristalsis. Chadwick sign might be the result of pelvic congestion.

What is not a trend in the delivery of health care in the United States?

Greater emphasis has been placed on curing disease and disability than on preventing them. Rationale: Prevention now is emphasized. Hospitalization has been shortened to reduce cost. Acute care is increasingly done at home. Nurses now are more involved in postdischarge follow-up care.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that:

Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. Rationale: The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

With regard to the classification of neonatal bacterial infection, nurses should be aware that:

Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot. Rationale: Handwashing is an effective preventive measure for late-onset (health care-associated) infections because these infections come from the environment around the infant. Early-onset (congenital) infections are caused by the normal flora at the maternal vaginal tract. Congenital (early-onset) infections progress more rapidly than health care-associated (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.

During a client's physical examination, the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as:

Hegar sign. Rationale: At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occur; this is called the Hegar sign. The Chadwick sign is a blue-violet cervix caused by increased vascularity; it is seen around the fourth week of gestation. Softening of the cervical tip, which may be observed around the sixth week of pregnancy, is called the Goodell sign. (The McDonald's sign indicates a fast-food restaurant.)

Which finding, if present in both the male and female of a couple, could present an issue with regard to the couple's fertility?

History of endocrine problems. Rationale: A history of endocrine problems should be investigated further because it may have an effect on the couple's fertility. Age is a relative factor but the recorded age, 35 years, does not in itself represent a significant fertility factor unless there are additional factors. The fact that both the man and the woman have already had children is a favorable sign in fertility. Although hypertension is a relevant clinical finding, it may not have a direct bearing on the couple's fertility.

A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:

Hydralazine. Rationale: Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.

Preterm infants are more likely to become septic because:

IgG level is directly proportional to gestational age. Rationale: IgG levels are directly proportional to gestational age, being decreased in preterm infants, and reflect immune function. Levels of IgG and IgA are not adequate at birth and require time to become optimal. Serum complement levels are decreased at birth in preterm infants.

From the nurse's perspective, what measure should be the focus of the health care system in order to reduce the rate of infant mortality further?

Implementing programs to ensure women's early participation in ongoing prenatal care Rationale: Early prenatal care allows for early diagnosis and appropriate interventions to reduce the rate of infant mortality. An increased length of stay has been shown to foster improved self-care and parental education; however, it does not affect the incidences of leading causes of infant mortality, such as low birth weight. Early prevention and diagnosis reduce the rate of infant mortality. NICUs offer care to high-risk infants after they are born. Expanding the number of NICUs would offer better access for high-risk care, but this is not the primary focus for further reduction of infant mortality rates. A mandate that all pregnant women receive obstetrician care would be nearly impossible to enforce. Furthermore, certified nurse-midwives (CNMs) have been demonstrated to provide reliable, safe care for pregnant women.

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester?

Increased pulse rate

With regard to small-for-gestational age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that:

Infants with asymmetric IUGR have the potential for normal growth and development. Rationale: The infant with asymmetric IUGR has the potential for normal growth and development.IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits).

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:

Intense abdominal pain. Rationale: Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding, uterine activity, and cramping may be present in varying degrees for both placental conditions.

An infertile woman is about to begin pharmacologic treatment. As part of the regimen, she will take purified follicle-stimulating hormone (FSH) (urofollitropin [Metrodin]). The nurse instructs her that this medication is administered in the form of a/an:

Intramuscular injection Rationale: Urofollitropin is given by IM injection; the dosage may vary. It cannot be given by the other routes listed.

Women with inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with:

Intrauterine growth restriction. Rationale: Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction. Spina bifida is not associated with inadequate maternal weight gain; an adequate amount of folic acid has been shown to reduce the incidence of this condition. Diabetes mellitus is not related to inadequate weight gain. A mother with gestational diabetes is more likely to give birth to a large-for-gestational age infant. Down syndrome is the result of trisomy 21, not inadequate maternal weight gain.

Which priority intervention would be needed if the nurse suspected that an infant was septic?

Intravenous access Rationale: Establishing intravenous access for the administration of antibiotics would be a priority intervention. The other actions described might be required but are not the priority intervention.

Which PPH conditions are considered medical emergencies that require immediate treatment?

Inversion of the uterus and hypovolemic shock Rationale: Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin; coagulopathies should have been identified prior to delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment; ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications but are not medical emergencies requiring immediate intervention.

Nurses should be aware that HELLP syndrome:

Is characterized by hemolysis, elevated liver enzymes, and low platelets. Rationale: The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. It is difficult to identify, because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased with HELLP syndrome, and so is perinatal mortality.

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST):

Is considered to have a negative result if no late decelerations are observed with the contractions. Rationale: No late decelerations indicate a positive CST result. Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is performed by IV oxytocin but not if by nipple stimulation. CST is contraindicated if the membranes have ruptured.

Nurses should be aware that infertility:

Is perceived differently by women and men. Rationale: Women tend to be more stressed about infertility tests and to place more importance on having children. The prevalence of infertility is stable among the overall population, but it increases with a woman's age, especially after age 40. Of cases with an identifiable cause, about 40% are related to female factors, 40% to male factors, and 20% to both partners.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features:

Is typified by auditory or visual hallucinations. Rationale: Hallucinations are present in 25% of women with this disorder; paranoid or grandiose delusions (present in 50%), elements of delirium or disorientation, and extreme deficits in judgment accompanied by high levels of impulsivity may contribute to risks of suicide or infanticide. PPD is more likely to occur in first-time mothers. PPD with psychosis is a psychiatric emergency that requires hospitalization.

For diagnostic and treatment purposes, nurses should know the birth weight classifications of high risk infants. For example, extremely low birth weight (ELBW) is the designation for an infant whose weight is:

Less than 1000 g. Rationale: ELBW is defined as less than 1000 g. At such weights, problems are so numerous that ethical issues regarding when to treat arise. Less than 1500 g is the designation for very low birth rate (VLBW). Less than 2000 g is less than LBW but too high for VLBW. Gestational age is a factor with weight in the condition of the preterm birth, but it is not part of the birth weight categorization.

When teaching self-care prevention of genital tract infections, the nurse should instruct the woman to:

Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bath. rationale: Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials (like nylon) create an environment in which a vaginal fungus can grow. Bathing in bath salts or bubble bath may further irritate sensitive genital tissue. Douching can irritate tissue, alter pH, and create an environment conducive to fungal growth. Prevention of genital tract infections includes reducing dietary sugar and eating yogurt.

A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family doctor has retired, and she is coming to see the women's health nurse practitioner for her visit. To facilitate a positive health care experience, the nurse should:

Listen carefully and allow extra time for this woman's health history interview. Rationale: The nurse has an opportunity to use reflection and empathy while listening and can ensure open and caring communication. Scheduling a longer appointment time may be necessary because older women may have longer histories or may need to talk. The comment in A is inappropriate. The client should be given positive reinforcement for coming in for her appointment even though it has been some time. A respectful and reassuring approach will ensure that women ages 50 and older will continue to seek care. The comment in C should be rephrased in a more positive manner. The nurse has an opportunity to use empathy and reflection; however, this is not the purpose of the client's visit. If the client continues to express grief over the loss of her husband, she can be referred to an appropriate support group or counseling.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturation values of 80%. The prescribed saturation value is 92%. The nurse's most appropriate action is to:

Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that:

MSAFP is a screening tool only; it identifies candidates for more definitive procedures. Rationale: CVS does provide a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. MSAFP screening is recommended for all pregnant women. MSAFP, not PUBS, is part of the quad-screen tests for Down syndrome. MSAFP is a screening tool, not a diagnostic tool. Further diagnostic testing is indicated after an abnormal result.

Which of the following findings is not likely to be seen in a pregnant patient who has hypothyroidism?

Macrosomia Rationale: Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm; these outcomes can be improved with early diagnosis and treatment. Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism.

Which findings would lead to increased bilirubin levels in the newborn?

Meconium passed after 24 hours Initiation of newborn feedings delayed following birth Twin-to-twin transfusion syndrome Rationale: Delay in passage of meconium or in newborn feedings could lead to increased bilirubin levels because of increased enterohepatic circulation. Twin-to-twin transfusion syndrome could lead to increased bilirubin levels as a result of an increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping were delayed following birth. Hypoglycemia could lead to increased bilirubin levels because of alterations in hepatic function and perfusion.

With regard to the most common bacterial sexually transmitted infections, which statement is not accurate?

Medications for pelvic inflammatory disease can be discontinued once symptoms disappear. Rationale: For any infection, the entire prescription must always be taken.

A pregnant patient is experiencing some integumentary changes and is concerned that they may represent abnormal findings. The nurse provides information to the patient that the following findings would be considered "normal abnormal" findings during pregnancy so that she should not be alarmed.

Melasma Linea nigra Vascular spiders Rationale: Facial edema is a concern because it can represent toxemia of pregnancy. Superficial thrombophlebitis is a concern because it can represent a risk factor for development of a DVT during pregnancy. The presentation of allodynia (pain upon normal touch) is considered to be a significant finding and requires additional investigation. Melasma (also known as the mask of pregnancy or chloasma), linea nigra (a hyperpigmentation line extending from the fundus to the symphysis pubis), and the presence of vascular spiders are all considered to be normal abnormal findings in pregnancy.

Which of the following antihypertensive medications would cause a pregnant woman to have a positive Coombs test result?

Methyldopa (Aldomet) rationale: A positive Coombs test result can occur in about 20% of patients taking methyldopa (Aldomet). None of the other drugs listed would have this effect.

What type of cultural concern is the most likely deterrent to many women seeking prenatal care?

Modesty Rationale: A concern for modesty is a strong deterrent to many women seeking prenatal care; for some women, exposing body parts, especially to a man, is considered a major violation of modesty. There are other deterrents. Even if the prenatal care described is familiar to a woman, some practices may conflict with the beliefs and practices of a subculture group or religion to which she belongs. For many cultural groups a physician is deemed appropriate only in times of illness. Because pregnancy is considered a normal process and the woman is in a state of health, the services of a physician are considered inappropriate. Many cultural variations are found in prenatal care, so ignorance is not likely to be a deterrent to women seeking prenatal care.

Nurses are getting ready for bedside reporting at change of shift. A benefit of this type of change of shift report is that:

Nurses are able to visualize their patient's directly at the time of report leading to better patient satisfaction. Rationale: Using a bedside report technique helps the nurse directly visualize the patient in question so as to improve his/her understanding of each patient's clinical situation. The transparency of information is not a benefit of bedside reporting. A bedside report is a change-of-shift report between nurses involved in the delivery of health care to a patient and/or group of patients; it is not mediated by patient questioning. Also, it is not all inclusive because patient care continues and is evolving over the course of the patient's hospitalization. Thus, additional information will be needed.

A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure?

Observe the patient for possible uterine contractions. Administer RhoGAM to the patient if she is Rh negative. Rationale: Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of transabdominal needle. There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.

Semen analysis is a common diagnostic procedure related to infertility. In instructing a male client regarding this test, the nurse would tell him to:

Obtain the specimen after a period of abstinence from ejaculation of 2 to 5 days. Rationale: An ejaculated sample should be obtained after a period of abstinence to get the best results. The male must ejaculate into a clean container or a plastic sheath that does not contain a spermicide. He should avoid exposing the specimen to extremes of temperature, either heat or cold, and the specimen should be taken to the laboratory within 2 hours of ejaculation.

In providing health promotion education to reduce the likelihood of transmission of sexually transmitted diseases, the nurse would describe which of the following practices as having a low but potential risk for disease transmission?

Oral sex with female or male wearing condom Vaginal intercourse with condom Rationale: Erotic conversation would be considered a safe risk reduction practice. Oral-anal contact and blood contact during a sexual act due to menses would be considered high-risk practices. Both oral sex and vaginal sex while wearing condoms are practices with low but potential risks.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about a half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis?

PPD can easily go undetected. Rationale: PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers, because PPD may also occur in new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.

A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority?

Place the woman in the knee-chest position. Rationale: The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Relieving pressure on the cord is the nursing priority. The nurse may also use her gloved hand or two fingers to lift the presenting part off the cord. If the cord is protruding from the vagina it may be covered with a sterile towel soaked in saline. The nurse should administer O

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency to every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:

Placental abruption. Rationale: Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests with hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain, and placenta previa with bright red, painless vaginal bleeding.

What would a breastfeeding mother who is concerned that her baby is not getting enough to eat find most helpful and most cost-effective on the day after discharge?

Placing a call to the hospital nursery warm line Rationale: The first course of action should be to call a warm line for advice from a nurse. Warm lines are telephone lines offered as a community service, in this case to provide new parents with support, encouragement, and basic parenting education.

Which laboratory values would be found in a patient diagnosed with preeclampsia?

Platelet count of 75,000 LDH 100 units/L BUN 25 mg/dL Rationale: Thrombocytopenia below 100,000, an increase in LDH, and an increase in BUN would be noted. Hemoglobin levels would be increased, but 8 g/dL reflects a decreased level.Burr cells would not be present in preeclampsia but would in HELLP syndrome.

A nurse is advising a pregnant patient who has a substance abuse problem about a contingency management program. Which statement identifies an aspect of this type of program?

Pregnant woman are given motivational incentives as a primary approach to stop their drug abuse problem. Rationale: A contingency management program utilizes a motivational incentive approach with patients to support their efforts to maintain abstinence. The incentives may include small cash amounts, privileges, or prizes. Contingency management programs are not limited to inpatient settings and do not involve biofeedback modalities or medication nutritional programs.

A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a:

Primipara

The most conservative approach for early breast cancer treatment involves lumpectomy followed by which procedure?

Radiation therapy

After change of shift report, the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is:

Referred Rationale: As labor progresses the woman often experiences referred pain. It occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and the thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. It results from stretching of the perineal tissues and the pelvic floor and occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

Which description of postpartum restoration or healing times is accurate?

Rugae reappear within 3 to 4 weeks. Rationale: Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

Which of the following lab tests would be indicated for a victim of sexual assault?

Screening test for hepatitis B Oral swab DNA testing Serum blood pregnancy test Rationale: Testing for Hepatitis B would be warranted because of blood transmission. Testing for confirmation of DNA would be indicated in a sexual assault case. Testing for pregnancy, urine or blood would be indicated in a sexual assault case. Typically, gonorrhea cultures would not be indicated because treatment would be given prophylactically to a sexual assault victim and therefore the results would not affect clinical practice. There is no need for fecal occult blood testing unless there is some other presenting clinical indication. Unless there is evidence of blood loss, a chemistry profile and complete blood count may not be needed.

The nurse should refer a client for further testing if which of the following was noted on inspection of a 55-year-old woman's breasts:

Small dimple located in the upper outer quadrant of the right breast Rationale: A small dimple is an abnormal finding and should be further evaluated. In many women, one breast is smaller than the other. Eversion of both nipples and a faintly visible venous network are both normal findings.

A newborn male, estimated to be 39 weeks of gestation, exhibits:

Testes descended into the scrotum. Rationale: A full-term male infant has both testes descended into his scrotum and rugae appear on the anterior portion. A full-term infant's good muscle tone results in a more flexed posture when at rest. A full-term infant exhibits only a moderate amount of lanugo, usually on the shoulders and back. Preterm infants have an abundance of lanugo over the entire body. The muscle tone of a full-term newborn prevents him from being able to move his elbow past midline.

The nurse knows that the second stage of labor, the descent phase, has begun when:

The cervix cannot be felt during a vaginal examination. Rationale: The second stage of labor begins with full cervical dilation. During the active pushing phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as at 5 cm dilation.

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:

The examiner's hand should be placed over the fundus before, during, and after contractions. Rationale: The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

With regard to hemolytic diseases of the newborn, nurses should be aware that:

The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth. Rationale: An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

When providing an infant with a gavage feeding, what should the nurse document each time?

The infant's response to the feeding Rationale: Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Some older infants may be learning to suck, but the important factor to document is the infant's response to the feeding (including attempts to suck). Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained prior to feeding, but the infant's response is more important.

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that:

The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. Rationale: Congenital malformations account for 30% to 50% of perinatal deaths in diabetic pregnancies. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome, and the transition to extrauterine life is often marked by hypoglycemia and other metabolic abnormalities.

Which action taken made by the nurse would indicate that he or she is practicing appropriate family-centered care techniques?

The nurse encourages the mother and father to make choices whenever possible. Rationale: With family-centered maternity care (FCMC), it is important to allow for choices for the couple and to include the partner in the care process. Also, FCMC involves collaboration between the health care team and the client. Unless there is an institutional policy prohibiting the number of attendees at a birth, the client should be allowed to have whomever she desires with her. In a family-centered care model, the partner or even a grandparent may be present for a cesarean birth (unless of course the birth is an emergency, for which guests may be requested to leave).

In a variation of rooming-in called couplet care, the mother and infant share a room and the mother shares the care of the infant with:

The nurse. Rationale: In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. This may also be known as mother-baby care or single-room maternity care. The father is included in instruction regarding infant care whenever he is present. The grandmother is welcome to stay and take part in the woman's postpartum care, but she is not part of the couplet. An older sibling may stay with the client and her baby but is also not part of the couplet

Which statement about female sexual response is not accurate?

The orgasmic phase is the final state of the sexual response cycle. Rationale: Men and women are surprisingly alike. Arousal is characterized by increased muscular tension (myotonia). Vasocongestion causes vaginal lubrication and engorgement of the genitals. The final state of the sexual response cycle is the resolution phase after orgasm. INCORRECT

Which of the following are examples of differences between primary and secondary dysmenorrhea?

The pain associated with primary radiates to the back and thighs With primary, the pain originates at the beginning of menses. With secondary, the pain can occur also during ovulation. With primary, the patient often presents with systemic symptoms such as dizziness and headache. Rationale: In primary dysmenorrhea, the patient typically presents with abdominal pain that is dull in nature and radiates to the back and thighs. The pain begins at the start of menses and lasts approximately 8 to 48 hours. The patient presents with systemic complaints as a result of increased prostaglandins and can have gastrointestinal as well as central nervous system symptoms. The patient often complains of cramping. In secondary dysmenorrhea, pain can also occur during ovulation, whereas in primary dysmenorrhea, the pain is associated only with ovulatory cycles.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which of the following is a facilitating behavior?

The parents hover around the infant, directing attention to and pointing at the infant. Rationale: Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. The other choices are inhibiting behaviors.

A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count (DFMC). Which instructions could be included in the plan of care?

The patient can monitor fetal activity once daily for a 60-minute period and note activity. Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted. Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted. Rationale: The fetal alarm signal is reached when no fetal movements are noted for a period of 12 hours.

A pregnant woman has maternal phenylketonuria (PKU) and is interested in whether or not she will be able to breastfeed her baby. Which reaction by the nurse indicates accurate information?

The patient should be advised to not breastfeed the infant because her breast milk will contain large amounts of phenylalanine. Rationale: Breastfeeding is not advised for a patient who has maternal PKU, because phenylalanine levels are high in such a patient's breast milk. Dietary restriction will not limit the amount of this substance in breast milk. Alternating feeding sources is not advised either.

With regard to emergency contraception pills, nurses should be aware that:

The pills should be readily available during the initial learning phase when a woman is using a new method of contraception. Rationale: A backup method of birth control is also a good idea for beginners. The woman has up to 120 hours after unprotected intercourse to take emergency contraception pills; they do not, however, protect against pregnancy from subsequent unprotected intercourse. These pills are contraindicated during pregnancy and if the woman has undiagnosed abnormal vaginal bleeding.

A 22-year-old woman pregnant with a single fetus had a preconception body mass index (BMI) of 24. When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lbs) since conception. How would the nurse interpret this finding?

The woman's weight gain is appropriate for this stage of pregnancy. Rationale: During the first trimester, the average total weight gain is only 1 to 2.5 kg. The desirable weight gain during pregnancy varies among women. Weight gain should take place throughout the pregnancy. The optimal rate depends on the stage of the pregnancy. The primary factor to consider in making a weight gain recommendation is the appropriateness of the prepregnancy weight for the woman's height. A commonly used method of evaluating the appropriateness of weight for height is the BMI. This woman's BMI is within the normal range, and she has gained the appropriate amount of weight for her size at this point in her pregnancy. Although the statements in A through C are accurate, they do not apply to this client.

What important aspects do all the fertility awareness-based (FAB) methods have in common?

They all require the cooperation of the woman's partner. Rationale: Fertile phases can be determined in a number of ways, but the sexual partner must cooperate in the method. Not all FAB methods calculate fertility phases by examining mucus; some use body temperatures and other signs. Some methods use chemical or physical barriers to conception during fertile periods.

Which statement accurately reflects the La cuarentena ritual for a Hispanic patient?

This ritual occurs over a period of 40 days. Rationale: The La cuarentena ritual occurs during a period of 40 days. The La cuarentena ritual period involves certain dietary and behavioral restrictions—spicy foods are restricted—and involves an intergenerational family approach toward integrating the family unit.

Which statement is accurate with regard to the emotional state of grief?

Time limit for grief experiences is variable among individuals. Rationale: There is no prescribed time limit for the expression of grief. Grief is a dynamic concept involving complex emotions. The expression of grief is individualized and may not occur simultaneously across family units. The process of grief represents an iterative process.

A Gravida III, Para 0 is concerned about the potential outcome for this pregnancy because all of her prior pregnancies have resulted in stillborn deliveries. Which diagnostic test would help assess for fetal well-being now that her pregnancy is at 32 weeks gestation?

Ultrasound Rationale: An ultrasound could be used to determine fetal well-being. The Kleihauer-Betke test is a blood test to evaluate for the presence of fetal blood in maternal circulation; there is no evidence to support the use of this test at this time. CVS testing is typically done earlier in the pregnancy, between 10 and 12 weeks. There is no evidence to support the use of a CST at this time; determination of fetal well-being would first be evaluated with a nonstress test

Which statement is inaccurate with regard to a nurse working with parents who have a sensory impairment?

Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact. Rationale: Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals throws up an additional and unneeded hurdle for the parents. After the parents' capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help a pick up a child's cry. Sign language is acquired readily by young children.

The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they:

Wash the top of can and can opener with soap and water before opening the can. Rationale: Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it.

In helping the breastfeeding mother position the baby, the nurse should keep in mind that:

Whatever the position used, the infant is "belly to belly" with the mother. Rationale: The infant inevitably faces the mother, belly to belly. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head, because doing so might cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

Under which circumstance would a nurse not perform a vaginal examination on a patient in labor?

When accelerations of the fetal heart rate (FHR) are noted Rationale: An accelerated FHR is a positive sign not requiring vaginal examination; variable decelerations, however, merit a vaginal examination. Vaginal examination should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is another appropriate time to perform a vaginal examination, as is after rupture of membranes (ROM). The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM.

With regard to dysfunctional labor, nurses should be aware that:

Women experiencing precipitous labor are about the only women experiencing dysfunctional labor who are not exhausted. Rationale: Precipitous labor lasts less than 3 hours. Short women more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years.