Reproductive System
19. A nurse teaches a group of postpartum clients that all their newborns will be screened for phenylketonuria (PKU) to: A. Assess protein metabolism. B. Reveal potential retardation. C. Detect chromosomal damage. D. Identify thyroid insufficiency
Correct Answer: A Phenylalanine is an essential amino acid necessary for growth that may be absent in infants with PKU; testing is performed in all neonates born in the United States. Untreated PKU can lead to retardation.
23. When calculating an Apgar score for a newborn, what does the nurse assess in addition to the heart rate? A. Muscle tone B. Amount of mucus C. Degree of head lag D. Depth of respirations
Correct Answer: A The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color.
25. What characteristic that may be a potential nutrition problem should the nurse identify in a preterm neonate? A. Inadequate sucking reflex B. Diminished metabolic rate C. Rapid digestion of formula D. Increased absorption of nutrients
Correct Answer: A The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting.
36. Respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks' gestation. What should the nurse's assessment reveal at this time? A. High-pitched cry B. Intercostal retractions C. Heart rate of 140 beats/min D. Respiratory rate of 20 beats/min
Correct Answer: B Intercostal contractions are a classic sign of RDS in the newborn. High-pitched cry is associated with neurologic impairment, not respiratory distress. The average number of respirations per minute of the healthy newborn is 30 to 50. The respiratory rate increases, not decreases, with RDS. The heart rate for healthy newborns ranges from 100 beats/min when sleeping to 180 beats/min when crying. A rate of 140 beats/min is within this range.
40. Shortly after giving birth, a client says she feels that she is bleeding. When checking the fundus, a nurse observes a steady trickle of blood from the vagina. What is the nurse's initial action? A .Calling the health care provider B. Checking the blood pressure and pulse C. Holding the fundus firmly and gently massaging it D. Explaining that the trickling blood is a common occurrence
Correct Answer: C A relaxed uterus is the most frequent cause of bleeding in the early postpartum period. The uterus may be returned to a state of firmness with the use of intermittent gentle fundal massage.
37. A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: A. Oxidization of fatty acids B. Shivering when chilled C. Metabolism of brown fat D. Increased muscular activity
Correct Answer: C Metabolism of brown fat releases energy and increases heat production in the newborn.
26. A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response? A. "An oxytocic." B. "An analgesic." C. "A corticosteroid." D. "A beta-adrenergic."
Correct Answer: D Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex.
24. Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? A. Cerebral palsy B. Neonatal syphilis C. Fetal alcohol syndrome D. Opioid drug withdrawal
Correct Answer: D These adaptations indicate opioid drug withdrawal; the infant should be monitored for further withdrawal signs during the first 24 hours after birth.
22. How should a nurse screen the newborn of a diabetic mother for hypoglycemia? A. Testing for glucose tolerance B. Drawing blood for a serum glucose determination C. Arranging for a fasting blood glucose determination D. Testing heel blood with the use of a glucose-oxidase strip
Correct Answer: D Glucose-oxidase strips are used by nurses to screen infants for hypoglycemia.
34. A couple is concerned about the risks associated with an in vitro fertilization embryo transfer (IVF-ET).Which of the following is a risk factor associated with IVF? A. Embryonic HIV B. Tubal pregnancy C. Congenital anomalies D. Hyperemesis gravidarum
Correct Answer: B There is an increased risk of tubal pregnancy with IVF-ET. There is not an increased risk for embryonic HIV infection, congenital anomalies, or hyperemesis gravidarum with IVF-ET.
6. A client with mild preeclampsia is told that she must remain on bedrest at home. The client starts to cry and tells the nurse that she has two small children at home who need her. How should the nurse respond? A. "Let's explore your available current support and opportunities for child care." B. "Are you worried about how you'll be able to handle this problem?" C. "You can get a neighbor to help out, and your husband can do the housework in the evening." D. "You can prepare light meals and the children can go to nursery school a few hours each day."
Correct Answer: A Asking the client how she plans to manage with getting child care help addresses the problem directly while providing an opportunity for the client to examine her options.
33. A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor? A. Scheduling pain medication at regular intervals B. Administering the medication only when the pain is severe C. Avoiding the administration of medication unless it is requested D. Recognizing that less pain medication will be needed by this client compared with other women in labor
Correct Answer: A This client will have lower tolerance for pain and greater need for pain relief. Larger doses may be needed if pain medication is administered only when the pain is severe. Delays increase anxiety and discomfort, and larger doses are needed. Individuals who abuse drugs need more medication than do others because of tolerance to the addictive drug.
10. Two days after being discharged a new mother calls the clinic stating that she is not sure that her baby is receiving enough breast milk. What information does the nurse need to determine whether the infant is being fed adequately? A. Voids four times before 2 pm B. Sleeps 3½ to 4 hours between feedings C. Has two or more bowel movements each day D. Nurses 5 minutes on the first breast and 10 on the other
Correct Answer: A Typically six to eight wet diapers a day indicates adequate fluid intake. Sleeping 3½ to 4 hours between feedings may be a sign of inadequate nutritional intake. A breastfeeding infant usually sleeps 1½ to 2½ hours between feedings because breast milk is digested rapidly.
12. A postpartum client intends to breastfeed her infant for the first time. How should the nurse assist the client? A. Feeding the infant formula first to evaluate the ability to suck B. Positioning the infant to grasp the nipple so as to express fluid C. Leaving the pair alone to allow the infant to nurse as long as desired D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: D Stimulating the rooting reflex is an effective way of making the infant grasp the nipple and areola.
1. A female client with Hodgkin's disease is to start chemotherapy. She and her husband have been trying to have a child and are quite concerned when they learn that sterility may result. On what information should the nurse base the reply? A. Ova can be harvested and frozen for future use. B. Chemotherapy is not radical enough to destroy ovarian function. C. Ovarian function will be temporarily destroyed but will return in time. D. Radiation can be substituted for chemotherapy to preserve ovarian function
Correct Answer: A Women in their childbearing years who have cancer should be informed of all options available to preserve their ability to reproduce. Chemotherapy can depress or destroy ovarian function. Destroyed ovarian function cannot be reversed; it is permanent. Both radiation and chemotherapy can destroy ovarian function.
29. What is the best method for the nurse to use when assessing blood loss in a client with placenta previa? A. Count or weigh perineal pads. B. Monitor pulse and blood pressure. C. Check hemoglobin and hematocrit values. D. Measure or estimate the height of the fundus.
Correct Answer: A An accurate measurement of the amount of blood loss may be obtained by counting or weighing pads.
20. A nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? A. Flaring nares B. Acrocyanosis C. Heartbeat of 140 beats/min D. Respirations of 40 breaths/min
Correct Answer: A Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and increase oxygen intake.
32. A pregnant client has class II cardiac disease. To best plan the client's care, the nurse should consider that the client: A. May participate in as much activity as she desires B. Should be hospitalized if there is evidence of cardiac decompensation C. Will have to maintain bedrest for most of the day throughout her pregnancy D. May have to consider a therapeutic abortion if there is evidence of cardiac decompensation
Correct Answer: B Clients with cardiac disease should be taught the signs and symptoms of cardiac decompensation; if they occur, the client should stop the activity that precipitated them and notify the health care provider.
27. A client at 37 weeks' gestation arrives at the emergency department stating that she is experiencing abdominal pain but no vaginal bleeding. The health care provider diagnoses abruptio placentae. The client asks the nurse why it is so painful. What should the nurse consider as the initial cause of the abdominal pain before responding in language that the client will understand? A. Hemorrhagic shock B. Concealed hemorrhage C. Blood in the myometrium D. Disseminated intravascular coagulation
Correct Answer: B The blood cannot escape from behind the placenta; the abdomen becomes boardlike and painful because of the entrapment of blood.
11. An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the infant. Which dosage and route will the nurse use? A. 1.0 to 1.5 mg given intramuscularly B. 0.5 to 1.0 mg given intramuscularly C. 1.0 to 1.5 mg given subcutaneously D. 0.5 to 1.0 mg given subcutaneously
Correct Answer: B The correct dosage of vitamin K is 0.5 to 1.0 mg, and the correct route is intramuscular. Vitamin K is not given to infants subcutaneously.
15. A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect? A. Preterm labor B. Uterine inertia C. Placenta previa D. Abruptio placentae
Correct Answer: C A nontender uterus and bright-red bleeding are classic signs of placenta previa; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed.
16. A nurse is caring for a client at 42 weeks' gestation who is having a contraction stress test (CST). What does a positive result indicate? A. The placenta has stopped growing. B. The fetal lungs have not yet matured. C. The function of the placenta has diminished. D. The amniotic fluid is stained with meconium
Correct Answer: C During a CST uterine blood flow to the placenta decreases. When a decrease is too great, fetal hypoxia and late decelerations occur, reflecting diminished placental function
30. A nurse has just finished reviewing how anesthesia will be used during a vaginal birth for a client with class I heart disease. What type of anesthesia does the client discuss that indicates to the nurse that the teaching was effective? A. Spinal B. Inhalation C. Epidural regional D. Local perineal filtration
Correct Answer: C Epidural regional anesthesia provides the safest method of pain relief for clients with heart disease. If the client expends more energy than her heart can tolerate, especially during second stage labor, cardiac decompensation may occur.
17. When does a nurse caring for a client with eclampsia determine that the risk for another seizure has decreased? A. After birth occurs B. After labor begins C. 48 hours postpartum D. 24 hours postpartum
Correct Answer: C The danger of a seizure in a woman with eclampsia subsides when postpartum diuresis has occurred, usually 48 hours after birth; however, the risk for seizures may remain for as long as 2 weeks after delivery.
35. A nurse is teaching a pregnant client with type 1 diabetes at her first visit to the clinic how to minimize fetal/neonatal complications. What is the most important action for the client to take? A. Exercise daily. B. Adhere to the prescribed diet. C. Adhere to the management plan. D. Keep the scheduled appointments.
Correct Answer: C Therapeutic management involves a comprehensive plan that includes diet, exercise, regulation of insulin dosage based on frequent blood glucose testing, and scheduled medical supervision.
2. A client in the 22nd week of gestation is scheduled for ultrasonography. What should the nurse teach the client to do regarding preparation for this test? A. Avoid eating after midnight. B. Take an enema the night before. C. Bring someone along to the test to drive her home. D. Refrain from voiding for several hours before the test
Correct Answer: D A full bladder supports the uterus in the optimum position for visualization of the fetus.
5. After counseling, a client is scheduled to have a tubal ligation. As the nurse enters the client's room before the procedure, the client states, "After this, I can never get pregnant again. What a relief." How should the nurse respond? A. "You're right—after the tubal ligation you won't get pregnant again." B. "Even though you're relieved now, be sure that you really want this tubal ligation." C. "If you should decide to have another child, the tubal ligation can be reversed easily." D. "Although a tubal ligation is effective, there is a slight chance of you becoming pregnant."
Correct Answer: D A small percentage of women do become pregnant after tubal ligation; however, it is very rare. Telling the client that she won't become pregnant again after the tubal ligation is false reassurance. The client should be made aware of the slim likelihood of pregnancy after tubal ligation as part of informed consent.
3. A client who is pregnant for the first time attends the prenatal clinic. She tells the nurse, "I'm worried about gaining too much weight, because I've heard that it's bad for me." How should the nurse respond? A. "Yes, too much weight gain causes complications during pregnancy." B. "You'll have to follow a low-calorie diet if you gain more than 15 lb." C. "We're more concerned that you won't gain enough weight to ensure adequate growth of your baby." D. "A 25-lb weight gain is recommended, but the pattern of weight gain is more important than the total amount."
Correct Answer: D A sudden sharp increase in weight may indicate fluid retention related to preeclampsia. Weight gain is necessary to ensure adequate nutrition for the fetus.
31. A 35-year-old client is scheduled for a vaginal hysterectomy. She asks the nurse about the changes she should expect after surgery. How should the nurse respond? A. "You will stop ovulating." B. "Surgical menopause will happen immediately." C. "Sexual intercourse will be uncomfortable when you resume it." D. "A hysterectomy doesn't affect the chronological age when menopause usually occurs."
Correct Answer: D As the term hysterectomy implies, only the uterus is removed. The ovaries remain; therefore, the client will experience menopause around the same time as women who have functioning ovaries.
7. A woman in the family planning clinic has decided to use the diaphragm for contraception. What should the nurse teach her about using a diaphragm? A. Completely cover the outside of the diaphragm with spermicidal jelly or cream. B. Douche within 1 hour of intercourse to enhance the effectiveness of the diaphragm. C. Correct placement of the diaphragm leaves an inch between the diaphragm and the vaginal wall. D. Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm.
Correct Answer: D It is important to explain that the diaphragm must be inserted before intercourse and left in place for at least 6 hours afterward; removing the diaphragm too early could allow some still-motile sperm to ascend into the uterus.
28. A client with a history of endometriosis gives birth to a healthy infant. She expresses concern that the problems associated with endometriosis will return now that her pregnancy is over. What is the best response by the nurse response? A. "Pregnancy usually cures the problem." B. "Endometriosis usually causes early menopause." C. "You may need a hysterectomy if the problems recur." D. "Breastfeeding will delay the return of the endometriosis."
Correct Answer: D Lactation delays ovarian function during the postpartum period; therefore lactation will delay the return of endometriosis.
39. Before teaching a client about breastfeeding, what should the nurse consider about hormonal influences? A. A high level of progesterone stimulates the secretion of oxytocin. B. A high level of estrogen stimulates the secretion of lactogenic hormones. C. Milk secretion is under the control of postpartum hormones starting immediately after birth. D. Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex.
Correct Answer: D Several factors influence the secretion of oxytocin and the let-down reflex; these include suckling, nipple stimulation, sexual activity, and thoughts, sight, and/or odor of the infant.
8. At a client's first prenatal visit, the nurse-midwife performs a pelvic examination. The nurse states that the client's cervix is bluish purple, which is known as the Chadwick sign. The client becomes concerned and asks whether something is wrong. The nurse replies, "This is expected; it: A. Helps confirm your pregnancy" B. Is not unusual, even in women who are not pregnant" C. Occurs because the blood is trapped by the pregnant uterus" D. Is caused by increased blood flow to the uterus during pregnancy"
Correct Answer: D Stating that the Chadwick sign is caused by increased blood flow to the uterus during pregnancy underscores the normalcy of Chadwick's sign and provides a simple explanation of the cause; women often need reassurance that the physical changes associated with pregnancy are expected.
38. A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do? A. Stay in bed for at least 3 days. B. Keep the legs elevated while sitting. C. Apply a warm compress to the affected calf twice a day. D. Call an ambulance to go to the emergency department.
Correct Answer: D The client's description of her problem is indicative of thrombophlebitis; this is a medical emergency because it may precipitate a pulmonary embolism. The client must be assessed by a health care provider. Intravenous anticoagulants will probably be necessary.
13. A client expresses a desire to breastfeed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breastfeed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request? A. By telling the client that this is unnecessary because the infant is being fed by gavage B. By discouraging the client because of the time and effort it will take to pump her breasts C. By instructing the client that breast milk is inadequate because it does not contain the necessary nutrients D. By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired
Correct Answer: D The infant may be fed with breast milk by means of gavage, and the pumping will stimulate milk production that should be adequate when the infant is ready to breastfeed. Until that time, the infant may dry breastfeed after pumping or lie close to the mother's breast for nippling as long as the infant can tolerate it.
18. A nurse gives a nasogastric feeding to a preterm male infant. As the mother watches, she asks, "Would it hurt my baby to suck on a pacifier during the feeding?" How should the nurse respond? A. "There's no real benefit in using a pacifier. Also, there's a relationship between using a pacifier and the development of buck teeth." B. "If you want, he can suck on a pacifier now, but he may have problems later when he starts to suck from the breast or bottle" C. "It's difficult to determine the color of his lips while he's sucking on a pacifier. We'd rather wait until he's a little older." D. "Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings."
Correct Answer: D The pacifier may satisfy nonnutritive sucking needs and stimulate flow of saliva and digestive juices. Protruding ("buck") teeth are associated with thumb sucking. Sucking on a pacifier promotes adaptation later to the breast or bottle; it does not hamper it.
14. A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiologic response indicates to the nurse that the magnesium sulfate is having a therapeutic effect? A. Dilation of the cervix by 1 cm every hour B. Tightening and pain in the perineal area C. A decrease in blood pressure to 120/80 mm Hg D. A decrease in frequency and duration of contractions
Correct Answer: D The purpose of administering magnesium sulfate is to stop preterm labor. It is a tocolytic agent that relaxes uterine smooth muscle. Labor is progressing if dilation of the cervix continues.
21. A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? A. "Are you disappointed in how your baby looks?" B. "Don't worry—your baby's head will be round in a few days." C. "Is there anyone in your family whose head shape is similar to your baby's?" D. "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."
Correct Answer: D The shape of the newborn's head is most likely the result of "molding." As the baby's head moves down the birth canal, the bones move for easier passage of the head through the birth canal. The mother needs information that is straightforward and understandable.
4. A fetal monitor is applied to a client in labor. The nurse should take action in response to a fetal heart rate that: A. Remains at 140 beats/min during contractions B. Uniformly drops to 120 beats/min with each contraction C. Fluctuates from 130 to 140 beats/min unrelated to contractions D. Repeatedly drops abruptly to 90 beats/min unrelated to contractions
Correct Answer: D This fetal heart rate change is known as variable-type decelerations. This is indicative of umbilical cord compression that, left uncorrected, may lead to fetal compromise; interventions are directed at improving umbilical circulation.
9. What is the priority nursing intervention during the 2 hours after a cesarean birth? A. Evaluating fluid needs to maintain optimum hydration B. Monitoring the incision to help prevent the onset of infection C. Encouraging bonding to promote mother-infant interaction D. Assessing the lochia to identify the complication of hemorrhage
Correct Answer: D The amount and character of the lochia must be checked after a cesarean birth just as they are after a vaginal birth.