HESI Practice Maternity V1

37. Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the primary health care provider based on the interpretation that these findings may lead to which condition? 1. Respiratory arrest. 2. Bronchial pneumonia. 3. Intraventricular hemorrhage. 4. Epiglottitis.

. 1. Periods of apnea lasting longer than 20 seconds, mild cyanosis, and a heart rate of <100 bpm (bradycardia) are associated with a potentially life-threatening event and subsequent respiratory arrest. The neonate needs further evaluation by the primary health care provider. Pneumonia is associated with tachycardia, anorexia, malaise, cyanosis, diminished breath sounds, and crackles. Intraventricular hemorrhage is associated with prematurity. Assessment findings include bulging fontanels and seizures. Epiglottitis is a bacterial form of croup. Assessment findings include inspiratory stridor, cough, and irritability. It occurs most commonly in children age 3 to 7 years.

32. While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the primary health care provider? 1. Red reflex in the eyes. 2. Expiratory grunt. 3. Respiratory rate of 45 breaths/min. 4. Prominent xiphoid process.

. 2. An expiratory grunt is significant and should be reported promptly, because it may indicate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts. The presence of a red reflex in the eyes is normal. An absent red reflex may indicate congenital cataracts. A respiratory rate of 45 breaths/min and a prominent xiphoid process are normal findings in a term neonate.

11. Which of the following would the nurse include in the teaching plan for a 32- year-old female client requesting information about using a diaphragm for family planning? 1. Douching with an acidic solution after intercourse is recommended. 2. Diaphragms should not be used if the client develops acute cervicitis. 3. The diaphragm should be washed in a weak solution of bleach and water. 4. The diaphragm should be left in place for 2 hours after intercourse.

. 2. The teaching plan should include a caution that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with increased incidence of urinary tract infections. Douching after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermicidal jelly or cream should be used if intercourse is repeated during this period. CN: Reduction of risk potential; CL: Create

35. While performing a physical assessment on a term neonate shortly after birth, which of the following would cause the nurse to notify the primary health care provider? 1. Deep creases across the soles of the feet. 2. Frequent sneezing during the assessment. 3. Single crease on each of the palms. 4. Absence of lanugo on the skin.

. 3. A single crease across the palm (simian crease) is most commonly associated with chromosomal abnormalities, notably Down syndrome. Deep creases across the soles of the feet is a normal finding in a term neonate. Frequent sneezing in a term neonate is normal. This occurs because the neonate is a nose breather and sneezing helps to clear the nares. An absence of lanugo on the skin of a term neonate is a normal finding.

40. At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. The nurse interprets these findings as indicating that this neonate is most likely experiencing which of the following? 1. Drug withdrawal. 2. First period of reactivity. 3. A state of deep sleep. 4. Respiratory distress.

. 3. At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal.

33. After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate does which of the following? 1. Steps briskly when held upright near a firm, hard surface. 2. Pulls both arms and does not move the chin beyond the point of the elbows. 3. Turns head to the left, extends left extremities, and flexes right extremities. 4. Extends and abducts the arms and legs with the toes fanning open.

. 3. The tonic neck reflex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremities, and flexes the right extremities. This reflex disappears in a matter of months as the neonatal nervous system matures. The stepping reflex is demonstrated when the infant is held upright near a hard, firm surface. The prone crawl reflex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski reflex.

17. A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit? 1. Choose an appropriate infertility treatment method. 2. Acknowledge that only 50% of infertile couples achieve a pregnancy. 3. Discuss alternative methods of having a family, such as adoption. 4. Describe each of the potential causes and possible treatment modalities.

. 4. By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility.

43. The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to: 1. Bottle-feed the twins to prevent exhaustion and fatigue. 2. Plan for each parent to spend equal amounts of time with each twin. 3. Avoid assistance from other family members until attachment occurs. 4. Relate to each twin individually to enhance the attachment process.

. 4. It is believed that the process of attachment is structured so that the parents become attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to each twin individually, rather than as a unit, to enhance the attachment process. Mothers of twins are usually able to breast-feed successfully because the milk supply increases on demand. However, possible fatigue and exhaustion require that the mother rest whenever possible. It would be highly unlikely and unrealistic that each parent would be able to spend equal amounts of time with both twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage assistance from family and friends, because caring for twins or other multiple births (eg, triplets) can be exhausting for the family.

19. A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which of the following responses would be most helpful? 1. "Today's modern technology has resulted in a low maternal mortality rate." 2. "Don't concern yourself with things that happened in the past." 3. "In North America, mothers seldom die in childbirth." 4. "What is it that concerns you about pregnancy, labor, and childbirth?"

. 4. The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Asking the client about these concerns would be most helpful to determine the client's knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconceptions. Although the maternal mortality rate is low in the United States and Canada, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States and Canada include embolism, pregnancyinduced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring the client's need for a discussion about complications of pregnancy may further increase the client's anxiety. CN: Health promotion and maintenance; CL: Apply

12. After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching? 1. "I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case." 2. "If I get pregnant, I will have to be refitted for another diaphragm after childbirth." 3. "Before inserting the diaphragm, I should coat the rim with contraceptive jelly." 4. "If I gain or lose 20 lb (9.1 kg), I can still use the same diaphragm."

. 4. The client would need additional instructions when she says that she can still use the same diaphragm if she gains or loses 20 lb (9.1 kg). Gaining or losing more than 15 lb (6.8 kg) can change the pelvic and vaginal contours to such a degree that the diaphragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case. The client should be refitted for another diaphragm after pregnancy and childbirth because weight changes and physiologic changes of pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm. The client should use a spermicidal jelly or cream before inserting the diaphragm. CN: Reduction of risk potential; CL: Evaluate

13. A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the incidence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods? Select all that apply. 1. Leafy green vegetables. 2. Strawberries. 3. Beans. 4. Milk. 5. Sunflower seeds. 6. Lentils.

1,2,3,5,6. The pregnancy requirement for folic acid is 600 mcg/day. Major sources of folic acid include leafy green vegetables, strawberries and oranges, beans, particularly black and kidney beans, sunflower seeds, and lentils. Milk and fats contain no folic acid. CN: Health promotion and maintenance; CL: Apply

14. A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan? 1. "Another method of contraception is needed until the sperm count is 0." 2. "Vasectomy is easily reversed if children are desired in the future." 3. "Vasectomy is contraindicated in males with prior history of cardiac disease." 4. "Vasectomy requires only a yearly follow-up once the procedure is completed."

1. Another method of contraception is needed until all sperm has been cleared from the body. The number of ejaculates for this to occur varies with the individual and laboratory analysis is required to determine when that has been accomplished. Vasectomy is considered a permanent sterilization procedure and requires microsurgery for anastomosis of the vas deferens to be completed. Studies have shown that there is no connection between cardiac disease in males and vasectomy. There is no need for follow-up after verification that there is no sperm in the system. CN: Physiological adaptation; CL: Create

25. A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result? 1. Bradycardia. 2. Rapid eye movement. 3. Seizures. 4. Tachycardia.

1. As a result of vigorous suctioning the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia.

42. A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following? 1. Orange juice. 2. Herbal tea. 3. Milk. 4. Grape juice.

1. Iron is best absorbed in an acid environment or with vitamin C. For maximum iron absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption.

1. A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses? 1. "I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy." 2. "My boyfriend can buy Plan B from the pharmacy if he is over 18 years old." 3. "The birth control works by preventing ovulation or fertilization of the egg." 4. "I may feel nauseated and have breast tenderness or a headache after using the contraceptive."

1. Plan B is a series of contraceptive pills similar in composition to birth control pills that have been used for the past 30 years. Plan B is the brand name for levonorgestrel 0.75 mg. Pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later. Males can purchase this contraceptive as long as they are over 18 years of age. Common side effects include nausea, breast tenderness, vertigo, and stomach pain. CN: Physiological adaptation; CL: Evaluate

5. Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate? 1. Take a mild analgesic if needed for menstrual pain. 2. Avoid cold foods if menstrual pain persists. 3. Stop exercise while menstruating. 4. Avoid sexual intercourse while menstruating.

1. The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or "cramps" are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases abdominal tone. Avoiding cold foods will not decrease dysmenorrhea. Sexual intercourse is not prohibited during menstruation, but the male partner should wear a condom to prevent exposure to blood. CN: Health promotion and maintenance; CL: Apply

10. A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning? 1. Using a spermicide with the condom offers added protection against pregnancy. 2. Natural skin condoms protect against sexually transmitted diseases. 3. The typical failure rate for couples using condoms is about 25%. 4. Condom users commonly report penile gland sensitivity.

1. The typical failure rate of a condom is approximately 12% to 14%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy. Natural skin condoms do not offer the same protection against sexually transmitted diseases caused by viruses as latex condoms do. Unlike latex condoms, natural skin (membrane) condoms do not prevent the passage of viruses. Most condom users report decreased penile gland sensitivity. However, some users do report an increased sensitivity or allergic reaction (such as a rash) to latex, necessitating the use of another method of family planning or a switch to a natural skin condom. CN: Health promotion and maintenance; CL: Apply

15. A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching? 1. "My fallopian tubes will be tied off through a small abdominal incision." 2. "Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%." 3. "After this procedure, I must abstain from intercourse for at least 3 weeks." 4. "Both of my ovaries will be removed during the tubal ligation procedure."

1. Tubal ligation, a female sterilization procedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy). Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the client may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries. CN: Health promotion and maintenance; CL: Evaluate

6. After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective? 1. "Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy." 2. "I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle." 3. "Sperms from a healthy male usually remain viable in the female reproductive tract for 96 hours." 4. "After an ovum is fertilized by a sperm, the ovum then contains 21 pairs of chromosomes."

1. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexually active. Many people believe that the time interval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmitted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the woman is most likely to conceive. Using a 28-day cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibility that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes. After fertilization, the conceptus contains 46 chromosomes unless there is a chromosomal abnormality. CN: Health promotion and maintenance; CL: Evaluate

45. A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge? Select all that apply. 1. "I know to wait 2 weeks before I start my birth control pills." 2. "I have the hospital phone number if I have any questions." 3. "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." 4. "My mother is coming to help for a month so I will be fine." 5. "I know if I get fever or chills or change in lochia to call the physician." 6. "I will continue my prenatal vitamins until my postpartum checkup or longer."

2, 3, 5, 6. The nurse is responsible for providing discharge instructions that include signs and symptoms that need to be reported to the physician as well as resources and follow-up for home care if needed. Phone numbers and health practices to promote healing, such as the use of prenatal vitamins, are also essential pieces of information. The use of birth control pills needs to be discussed with the physician. A progesterone-only pill is used if the client is breast-feeding. Oral contraceptives should be initiated according to the physician's advice. Although the client's mother may be helpful, the client's statement that she will be fine because her mother is coming indicates that she is unaware or ignoring information about valuable information and resources.

. A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the primary health care provider with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply. 1. Administer the IV antibiotic. 2. Hold the neonate steady in the correct position. 3. Ensure a patent airway. 4. Maintain a sterile field.

2,3,4. Holding the neonate steady and in the proper position will help ensure a safe and accurate lumbar puncture. The neonate is usually held in a "C" position to open the spaces between the vertebral column. This position puts the neonate at risk for airway obstruction. Thus, ensuring the patency of the airway is the first priority, and the nurse should observe the neonate for adequate ventilation. Maintaining a sterile field is important to avoid infection in the neonate. It is not necessary to administer antibiotics or obtain a serum glucose level during the procedure.

8. Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? 1. Anemia. 2. Hypertension. 3. Dysmenorrhea. 4. Acne vulgaris.

2. Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-deficiency anemia, dysmenorrhea, and acne are not contraindications for the use of oral contraceptives. Iron-deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, thereby providing a beneficial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives commonly improves facial acne. CN: Reduction of risk potential; CL: Analyze

34. A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus? 1. The neonate's eyes are unable to focus on light at this time. 2. Neonates commonly lack eye muscle coordination. 3. Congenital cataracts may be present. 4. The neonate is able to fixate on distant objects immediately.

2. Convergent strabismus is common during infancy until about age 6 months because of poor oculomotor coordination. The neonate has peripheral vision and can fixate on close objects for short periods. The neonate can also perceive colors, shapes, and faces. Neonates can focus on light and should blink or close their eyes in response to light. However, this is not associated with strabismus. An absent red reflex or white areas over the pupils, not strabismus, may indicate congenital cataracts. Most neonates cannot focus well or accommodate for distance immediately after birth.

39. Which of the following assessment findings in a term neonate would cause the nurse to notify the primary health care provider? 1. Absence of tears. 2. Unequally sized corneas. 3. Pupillary constriction to bright light. 4. Red circle on pupils with ophthalmoscopic examination.

2. Corneas of unequal size should be reported because this may indicate congenital glaucoma. An absence of tears is common because the neonate's lacrimal glands are not yet functioning. The neonate's pupils normally constrict when a bright light is focused on them. The finding implies that light perception and visual acuity are present, as they should be after birth. A red circle on the pupils is seen when an ophthalmoscope's light shines onto the retina and is a normal finding. Called the red reflex, this indicates that the light is shining onto the retina.

23. After the birth of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying and positioning the neonate, what should the nurse do next? 1. Assign the first Apgar score. 2. Start positive pressure ventilation. 3. Administer oxygen. 4. Start cardiac compressions.

2. If an infant is not breathing after the initial steps of resuscitation, the next thing the nurse must do is begin positive pressure ventilation. Apgar scores are an evaluation of the neonate's status at 1 and 5 minutes of life. Waiting to restore respirations until after assigning an Apgar score would be a waste of valuable time. Oxygen alone does little good if the infant is not breathing. Chest compressions must be accompanied by adequate oxygenation.

29. Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference? 1. Equal to the chest circumference. 2. Approximately 2 cm larger than the chest. 3. About 3 cm smaller than the chest. 4. Approximately 4 cm larger than the chest.

2. Normally at birth, the neonate's head circumference is approximately 2 cm larger than the chest circumference. The average normal head circumference is 13 to 14 inches (33 to 35 cm); average normal chest circumference is 12.5 to 14 inches (31 to 35 cm). A head circumference that is equal to or smaller than the chest circumference may indicate microcephaly; a head that is larger than normal may indicate hydrocephalus. The presence of any of these conditions warrants further evaluation.

41. A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds based on the understanding about which of the following? 1. Foods from home are generally discouraged on the postpartum unit. 2. The mother can bring the daughter any foods that she desires. 3. This is permissible as long as the foods are nutritious and high in iron. 4. The client's physician needs to give permission for the foods.

2. On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the physician's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hotcold" theory of disease; certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the mother to bring her daughter "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship.

22. A full-term neonate is admitted to the normal newborn nursery. The nurse notes a Moro reflex. What should the nurse do next? 1. Call a code. 2. Identify this reflex as a normal finding. 3. Place the neonate on seizure precautions. 4. Start supplemental oxygen.

2. The Moro reflex is a normal reflex of a neonate and requires no intervention. Calling a code, placing the neonate on seizure precautions, and starting supplemental oxygen are not necessary for a normally occurring reflex. CN: Basic care and comfort; CL: Synthesize

16. A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following? 1. Check the cervical mucus to see if it is thick and sparse. 2. Take her temperature at the same time every morning before getting out of bed. 3. Document ovulation when her temperature decreases at least 1°F (0.56°C). 4. Avoid coitus for 10 days after a slight rise in temperature.

2. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5°F (0.28°C). At the time of ovulation, the temperature rises 0.4°F to 0.8°F (0.22°C to 0.44°C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy. CN: Health promotion and maintenance; CL: Apply

26. When reviewing the prenatal history for a newly born neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for: 1. Acrocyanosis. 2. Café au lait spots. 3. Port wine nevus. 4. Strawberry hemangiomas.

2. There is a correlation between café au lait spots and the development of neurofibromatosis. Acrocyanosis is a normal finding of bluish hands and feet as a result of poor capillary perfusion. Port wine nevus and strawberry hemangiomas are a collection of dilated capillaries and are not associated with any other disease process.

21. The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn? 1. places the infant horizontally and in a prone position with one hand 2. left side 3. right side 4. stand infant up

21. 1. When assessing the incurving of the trunk tests for automatic reflexes in the newborn, the nurse places the infant horizontally and in a prone position with one hand, and strokes the side of the newborn's trunk from the shoulder to the buttocks using the other hand. If the reflex is present, the newborn's trunk curves toward the stimulated side. Answer 2 shows a figure for testing for a stepping response. Answer 3 shows a figure for testing for a tonic neck reflex. Answer 4 shows a figure for testing for the Moro (startle) reflex. CN: Physiological adaptation; CL: Apply

24. A 6-lb, 8-oz (2,948 g) neonate was born vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The Apgar score is: 1. 2. 2. 3. 3. 4. 4. 6.

3. The neonate has a heart rate >100, which earns him 2 points. His respiratory rate of 70 is equivalent to a 2 on the scale. His flaccid muscle tone is equal to 0 on the scale. The lack of response to stimulus also equals 0, as does his overall pale white color. Thus, the total score equals 4. CN: Basic care and comfort; CL: Apply

20. A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan? 1. About midway through the menstrual cycle, cervical mucus is thick and sticky. 2. During ovulation, the cervix remains dry without any mucus production. 3. As ovulation approaches, cervical mucus is abundant and clear. 4. Cervical mucus disappears immediately after ovulation, resuming with menses.

3. As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (±2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present. CN: Health promotion and maintenance; CL: Create

44. Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next? 1. Document this as a normal finding in the client's record. 2. Contact the physician for a prescription for oxytocin. 3. Encourage the client to ambulate to the bathroom and void. 4. Gently massage the fundus to expel the clots.

3. At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return it to midline, it should be reported to the physician. Oxytocin is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots. Reduction of risk potential; CL: Synthesize

2. An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options? 1. Satisfaction with prior methods. 2. Preference of sexual partner. 3. Breast- or bottle-feeding plan. 4. Desire for another child in 2 years.

3. Birth control plans are influenced primarily by whether the mother is breast- or bottle-feeding her infant. The maternal milk supply must be well established prior to the initiation of most hormonal birth control methods. Low-dose oral contraceptives would be the exception. Use of estrogen-/progesterone-based pills and progesterone-only pills are commonly initiated from 4 to 6 weeks postpartum because the milk supply is well established by this time. Prior experiences with birth control methods have an impact on the method chosen as do the preferences of the client's partner; however, they are not the most influential factors. Desire to have another child in two years would make some methods, such as an IUD, less attractive but would still be secondary to the choice to breast-feed. CN: Pharmacological and parenteral therapies; CL: Analyze

4. Which of the following would be important to include in the teaching plan for the client who wants more information on ovulation and fertility management? 1. The ovum survives for 96 hours after ovulation, making conception possible during this time. 2. The basal body temperature falls at least 0.2°F (0.17°C) after ovulation has occurred. 3. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. 4. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.

3. For a client with a typical menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body temperature rises 0.5°F to 1.0°F (0.28°C to 0.56°C) when ovulation occurs. Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious. CN: Health promotion and maintenance; CL: Create

28. After vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the primary health care provider based on the analysis that this may be indicative of which anomalies? 1. Respiratory anomalies. 2. Musculoskeletal anomalies. 3. Cardiovascular anomalies. 4. Facial anomalies.

3. Normally, the umbilical cord has two umbilical arteries and one vein. When a neonate is born with only one artery and one vein, the nurse should notify the primary health care provider for further evaluation of cardiac anomalies. Other common congenital problems associated with a missing artery include renal anomalies, central nervous system lesions, tracheoesophageal fistulas, trisomy 13, and trisomy 18. Respiratory anomalies are associated with dyspnea and respiratory distress; musculoskeletal anomalies include fractures or dislocated hip; and facial anomalies are associated with fetal alcohol syndrome or Down syndrome, not a missing umbilical artery.

31. Which of the following observations is expected when the nurse is assessing the gestational age of a neonate born at term? 1. Ear lying flat against the head. 2. Absence of rugae in the scrotum. 3. Sole creases covering the entire foot. 4. Square window sign angle of 90 degrees. 32. While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the primary health care provider? 1. Red reflex in the eyes. 2. Expiratory grunt. 3. Respiratory rate of 45 breaths/min. 4. Prominent xiphoid process.

3. Sole creases covering the entire foot are indicative of a term neonate. If the neonate's ear is lying flat against the head, the neonate is most likely preterm. An absence of rugae in the scrotum typically suggests a preterm neonate. A square window sign angle of 0 degrees occurs in neonates of 40 to 42 weeks' gestation. A 90-degree square window angle suggests an immature neonate of approximately 28 to 30 weeks' gestation.

18. A client is scheduled to have in vitro fertilization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure? 1. "IVF requires supplemental estrogen to enhance the implantation process." 2. "The pregnancy rate with IVF is higher than that with gamete intrafallopian transfer." 3. "IVF involves bypassing the blocked or absent fallopian tubes." 4. "Both ova and sperm are instilled into the open end of a fallopian tube."

3. The client's understanding of the procedure is demonstrated by the statement describing IVF as a technique that involves bypassing the blocked or absent fallopian tubes. The primary health care provider removes the ova by laparoscope- or ultrasoundguided transvaginal retrieval and mixes them with prepared sperm from the woman's partner or a donor. Two days later, up to four embryos are returned to the uterus to increase the likelihood of a successful pregnancy. Supplemental progesterone, not estrogen, is given to enhance the implantation process. Gamete intrafallopian transfer (GIFT) and tubal embryo transfer have a higher pregnancy rate than IVF. However, these procedures cannot be used for clients who have blocked or absent fallopian tubes because the fertilized ova are placed into the fallopian tubes, subsequently entering the uterus naturally for implantation. In IVF, fertilization of the ova by the sperm occurs outside the client's body. In GIFT, both ova and sperm are implanted into the fallopian tubes and allowed to fertilize within the woman's body. CN: Reduction of risk potential; CL: Evaluate

7. A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which of the following would the nurse include in the teaching plan? 1. This method has a 50% failure rate during the first year of use. 2. Couples must abstain from coitus for 5 days after the menses. 3. Cervical mucus is carefully monitored for changes. 4. The male partner uses condoms for significant effectiveness.

3. The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning.

36. Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management? Select all that apply. 1. "My baby can't have milk-based formulas." 2. "My baby will grow out of this by the age of 2." 3. "This is a hereditary disease, so any future children will have it, too." 4. "My baby will eventually become retarded because of this disease." 5. "We have to follow a strict phenylalanine diet." 6. "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."

36. 1,5,6. Phenylketonuria, an inherited autosomal recessive disorder, involves the body's inability to metabolize the amino acid phenylalanine. A diet low in phenylalanine must be followed. Such foods as meats, eggs, and milk are high in phenylalanine. Assistance from a dietitian is commonly necessary to keep phenylalanine levels low and to provide the essential amino acids necessary for cell function and tissue growth. With autosomal recessive disorders, future children will have a 25% chance of having the disease, a 50% chance of carrying the disease, and a 25% chance of being free of the disease. If a diet low in phenylalanine is followed until brain growth is complete (sometime in adolescence), the child should achieve normal intelligence. CN: Health promotion and maintenance; CL: Evaluate

38. A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: 1. 2 to 3 months. 2. 6 to 8 months. 3. 9 to 10 months. 4. 12 to 18 months.

4. Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in mental retardation. The posterior fontanel typically closes by ages 2 to 3 months.

30. After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction? 1. "The molding was caused by an overlapping of the baby's cranial bones during my labor." 2. "The amount of molding is related to the amount and length of pressure on the head." 3. "The molding will usually disappear in a couple of days." 4. "Brain damage may occur if the molding doesn't resolve quickly."

4. The mother needs further instruction if she says the molding can result in brain damage. Brain damage is highly unlikely. Molding occurs during vaginal birth when the cranial bones tend to override or overlap as the head accommodates to the size of the mother's birth canal. The amount and duration of pressure on the head influence the degree of molding. Molding usually disappears in a few days without any special attention.

3. After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful? 1. "I should perform breast self-examination on the day my menstrual flow begins." 2. "It's important that I perform breast self-examination on the same day each month." 3. "If I notice that one of my breasts is much smaller than the other, I shouldn't worry." 4. "If there is discharge from my nipples, I should call my health care provider."

4. The nurse determines that the client has understood the instructions when the client says that she will notify her primary health care provider if she notices discharge or bleeding because this may be symptomatic of underlying disease. Ideally, breast selfexamination should be performed about 1 week after the onset of menses because hormonal influences on breast tissue are at a low ebb at this time. The client should perform breast self-examination on the same day each month only if she has stopped menstruating (as with menopause). The client's breasts should mirror each other. If one breast is significantly larger than the other, or if there is "pitting" of breast tissue, a tumor may be present. CN: Reduction of risk potential; CL: Evaluate

9. After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which of the following as an adverse effect? 1. Weight gain. 2. Nausea. 3. Headache. 4. Ovarian cancer.

4. The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovarian and endometrial cancers are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is thrombophlebitis. CN: Pharmacological and parenteral therapies; CL: Evaluate