Leifer NCLEX Review Questions CH 1-8

Spermatozoa are produced in the: 1. vas deferens. 2. seminiferous tubules. 3. prostate gland. 4. Leydig cells.

1

The tissue between the vaginal opening and the anus is known as the 1. perineum. 2. cervix. 3. uterus. 4. ovary.

1

Varicosities of the rectum and anus that become more severe with constipation and with descent of the infant's head into the pelvis are called 1. hemorrhoids. 2. fissures. 3. hernias. 4. aneurisms.

1

What is the principal goal of nursing care during labor? 1. Promoting relaxation and helping the woman to conserve resources 2. Preparation of the delivery room with needed supplies 3. Assisting the obstetrician to gown and glove 4. Documenting the progression of the labor process

1

What is the primary benefit of an amniotomy to augment or induce labor? 1. Stimulate prostaglandin secretion 2. Prevent umbilical cord compression 3. Treat umbilical cord prolapse 4. Allow internal monitoring

1 Amniotomy is used to augment labor to stimulate prostaglandin secretion. Amniotomy can cause compression and prolapse. Amniotomy does allow for internal monitoring, but it is not the major benefit that helps augment labor.

What would the nurse expect a normal finding to be during assessment of the fundus of the uterus every 15 minutes during the fourth stage of labor? 1. Firm and at the umbilicus 2. Soft and deviated to the left 3. Firm and deviated to the right 4. Soft to touch, but firm with massage

1 During the fourth stage, recovery of labor, the uterus is normally found firmly contracted at or below the umbilicus level. Deviation to the right can indicate a full bladder. A boggy or soft uterus can indicate a potential complication. The uterus is not usually found deviated to the left.

A patient is 28 weeks pregnant and has pregnancy-induced hypertension. Which symptom would indicate that her condition is worsening? 1. Epigastric pain 2. Dependent edema 3. Feelings of lethargy 4. Blood pressure of 138/90 mm Hg

1 Epigastric pain is a sign of worsening preeclampsia. Blood pressure of 138/90 mm Hg, dependent edema, and feelings of lethargy are not signs that preeclampsia is worsening.

The first sign of fluid retention in the pregnant woman diagnosed with gestational hypertension is 1. sudden, excessive weight gain. 2. headache. 3. abdominal pain. 4. blurred vision.

1 Sudden, excessive weight gain is the first sign of fluid retention. Visible edema follows the weight gain.

If the sacrum of the fetus in a breech presentation is in the mother's right posterior pelvis, it is described as 1. right sacrum posterior. 2. left mentum anterior. 3. transverse. 4. left occiput posterior.

1 The first word refers to what side of the mom's pelvis the presenting part is facing, the second is the fetal reference point (occiput for vertex presentations, mentum for face, and sacrum for breech), and the third references the front (anterior) or back (posterior) of the mother's pelvis. If the fetus is neither anterior nor posterior, then it is transverse.

Which symptoms should be reported to the obstetrician during the pregnancy? (Select all that apply.) 1. Sudden gush of fluid 2. Blurred vision 3. Vaginal bleeding 4. Vomiting during the first trimester 5. Frequent urination

1, 2, 3 A sudden gush of fluid could indicate rupture of membranes. Blurry vision could indicate preeclampsia. Vaginal bleeding could indicate abruption or tearing of the placenta. Vomiting and frequent urination are not rare occurrences during pregnancy.

What are the predisposing factors for abruptio placentae? (Select all that apply.) 1. Hypertension 2. Poor nutrition 3. Folate deficiency 4. Cigarette smoking 5. Excessive weight gain

1, 2, 3, 4 Folate deficiency, hypertension, abdominal trauma, poor nutrition, and cigarette smoking are all predisposing factors to abruptio placentae.

What signs of respiratory distress in the neonate should be reported immediately? (Select all that apply.) 1. Grunting respirations 2. Flaring of the nostrils 3. Heart rate above 110 beats/minute 4. Cyanosis of the hands and feet 5. Respiratory rate higher that 60 breaths/minute

1, 2, 5 Some signs of respiratory distress that should be immediately reported include grunting respirations, persistent cyanosis (other than hands and feet), flaring of the nostrils, retractions, sustained respiratory rate higher than 60 breaths/minute, and sustained heart rate greater than 160 beats/minute or less than 110 beats/minute.

Which are considered pharmacological methods to stimulate contractions? (Select all that apply.) 1. Prostaglandin gel 2. Amniotomy 3. Oxytocin administration 4. Nipple stimulation 5. Version

1, 3 Cervical ripening using prostaglandin gel and oxytocin administration (IV) is considered pharmacological methods to stimulate contractions. Amniotomy is the artificial rupture of membranes by using a sterile sharp instrument and can stimulate contractions but is not considered pharmacological. Stimulation of the nipples causes natural secretion of oxytocin and is a nonpharmacological method to stimulate contractions. Version is a method of changing the fetal presentation, usually from breech to cephalic.

What is true of family-centered care? (Select all that apply.) 1. The nurse's role is to enter into a partnership with the family. 2. The health care professionals are the primary decision makers. 3. The family's involvement during pregnancy and birth is seen as constructive necessary for bonding and support. 4. Families contribute their ability to accept and maintain control over the health care of family members. 5. Families will benefit from decreasing fragmentation of care by not changing rooms during the hospital stay.

1, 3, 4, 5

Which individuals played a role in decreasing infections for patients, increasing mortality to what it is today? (Select all that apply.) 1. Crede 2. Saint Vincent de Paul 3. Lister 4. Pasteur 5. Semmelweis

1, 3, 4, 5 Credé recommended instilling 2% silver nitrate into the eyes of newborns to prevent blindness caused by gonorrhea. Joseph Lister influenced by Pasteur, experimented with chemical means of preventing infection. He revolutionized surgical practice by introducing antiseptic surgery. Louis Pasteur confirmed that puerperal fever was caused by bacteria and could be spread by improper hand washing and contact with contaminated objects.

Which symptoms are expected changes during pregnancy? (Select all that apply.) 1. Constipation 2. Blurred vision 3. Breast enlargement 4. Skin discoloration 5. Mild vaginal bleeding 6. Nasal stuffiness

1, 3, 4, 6 Breast enlargement, constipation, nasal stuffiness, and skin discoloration can occur normally during pregnancy as a result of hormonal fluctuations. Vaginal bleeding and blurred vision can be signs of complications of pregnancy, such as abruptio placentae, eclampsia, and placenta previa, but are not expected findings in an uncomplicated pregnancy.

Which statements are true about puberty? (Select all that apply.) 1. The first outward change of puberty for a girl is development of breasts. 2. Male hormonal changes are complete by age 13. 3. Testosterone causes boys to develop secondary sex characteristics. 4. Hormonal changes for the male and female begin before age 10. 5. The first menstrual period in females occurs 2 to 2½ years after development of breasts.

1, 3, 5 Breast development is the first outward change of puberty in females. Male hormone changes may not be complete until age 16. Testosterone is the cause of secondary sex characteristics. Both sexes' hormonal changes begin after age 10. The first menstrual period does occur 2 to 2½ years after development of breasts.

Testosterone has what effects not related to reproduction? (Select all that apply.) 1. Increases sebum production 2. Decreases hematocrit in males 3. Decreases basal metabolic rate 4. Promotes growth of long bones 5. Increases muscle mass and strength

1, 4, 5 Testosterone promotes growth of long bones, increases sebum production, and increases muscle mass and strength. Testosterone is responsible for an increase in hematocrit and basal metabolic rate in males.

What are the positive signs of pregnancy? (Select all that apply.) 1. Fetal heart activity 2. Positive serum pregnancy test 3. Fetal movements felt by mother 4. Fetal outline identified by palpation 5. Visualization of fetus with ultrasound

1, 5 Positive signs of pregnancy are caused only by a developing fetus. They include demonstration of fetal heart activity, fetal movements felt by an examiner, and visualization of the fetus with ultrasound. Pregnancy tests and fetal outline are probable signs that provide stronger evidence of pregnancy but can be caused by other conditions. Quickening, or fetal movements felt by the mother, is a presumptive sign that also can be caused by abdominal gas, normal bowel activity, and false pregnancy.

A woman can keep a diary of her menstrual cycles to help determine her fertile period. She understands that after ovulation she will remain fertile for: 1. 2 hours. 2. 24 hours. 3. 3 to 5 days. 4. 7 to 14 days.

2

The experienced nurse is instructing the new nurse about communications concerning the patient. The nurse suggests using an SBAR method and lists the four elements included in the technique. Which four elements should be included in the instruction? 1. Shift-end report, background, assessment, and reassessment 2. Situation, background, assessment, and recommendation 3. Shift-end report, background, assessment, and recommendation 4. Situation, background, actual nursing diagnoses, and remedy

2

What is used to assess the status of the cervix in determining its response to induction? 1. Apgar score 2. Bishop score 3. Amniotomy 4. Prostaglandin secretion

2

When a pregnancy occurs outside the uterine cavity, it is referred to as a(n) 1. miscarriage. 2. ectopic pregnancy. 3. erythroblastosis fetalis. 4. preeclampsia.

2

Which is a diagnosis that the nurse is legally responsible to report? 1. Bronchiolitis 2. Sexually transmitted infections 3. Acute otitis media 4. Strep throat

2 All nurses have a legal and ethical responsibility to report sexually transmitted infections or other communicable diseases

What is the best description of erythroblastosis fetalis of the fetus and newborn? 1. An immune reaction of the fetus' blood against the Rh factor on the mother's red blood cells 2. An immune reaction by the mother's blood against the Rh factor on the fetus' red blood cells 3. Rh incompatibility disease that results in a hemoglobin value of 10g or less in the fetus or newborn 4. Rh disease that results in sickle cell disease in the fetus or newborn

2 Erythroblastosis fetalis (hemolytic disease) of the fetus and newborn is caused by an immune reaction by the mother's blood against the blood group factor on the fetus' red blood cells.

Which statement made by an expectant mother demonstrates understanding of the significant risks of home delivery? 1. "I know I will have access to the technology that monitors my well-being." 2. "I know that there will be a delay in emergency care if there is a complication." 3. "The physician will only come to my home if I have a complication." 4. "The midwife can perform most emergency procedures at home."

2 Mothers will not have access to technology at home. Most physicians will not come to the home for medical care. Most emergency procedures can only be performed in the hospital per standard of care. It is important that this mother understands that there will be a delay, creating significant risk, if there is a complication.

At what time during pregnancy would patient education focus mainly on physiologic changes, fetal development, sexuality during pregnancy, and nutrition? 1. Before conception 2. During the first trimester 3. During the second trimester 4. During the third trimester

2 The first trimester is when the woman focuses on herself; therefore, education should be geared toward answering questions and providing information directly related to the woman and changes of pregnancy. During the second and third trimesters, education focuses on preparation for birth, parenting, and newborn care. Pre-conception education is geared toward information relating to healthy living for conception.

What is the purpose of the administration of vitamin K (AquaMephyton) to a newborn? 1. Cord healing 2. Blood clotting 3. Respiratory status 4. Infection prevention

2 Vitamin K (AquaMephyton) is required by the newborn to assist in blood clotting. A newborn lacks vitamin K at birth because of a sterile gastrointestinal tract. Newborns receive a single dose of vitamin K into the vastus lateralis muscle before leaving the delivery room, usually at age 1 hour.

Which routine assessments are made at each prenatal visit? (Select all that apply.) 1. Glucose tolerance test (GTT) 2. Fundal height 3. Urinalysis for protein, glucose, and ketones 4. Fetal heart rate 5. Leopold's maneuvers

2, 3, 4 A glucose tolerance test is done one time, routinely around 28 weeks. Leopold's maneuvers are done closer to the delivery date to identify the position of the baby. Fundal height, UA, and fetal heart rate are all done routinely at each visit.

Which hormones have a role in the reproductive cycle for the female? (Select all that apply.) 1. Testosterone 2. Follicle-stimulating hormone 3. Luteinizing hormone 4. Estrogen 5. Progesterone 6. Cortisol

2, 3, 4, 5

A group of women are discussing childbirth experiences. Which statement would most likely indicate that the woman gave birth in the 1950s? 1. "My husband stayed with me throughout labor and birth." 2. "The suite allowed me to deliver and recover in the same room." 3. "I was discharged from the hospital 1 week following delivery." 4. "The birthing center rooms were decorated in a homelike fashion."

3 During the 1950s, the hospital stay for labor and delivery was 1 week. The other situations described would not have occurred until after 1960 with the natural childbirth movement.

Which data indicate that a woman may have pelvic dimensions that would be inadequate for a normal vaginal delivery? A woman with a(n): 1. anthropoid-shaped pelvis with a history of pelvic inflammatory disease 2. gynecoid-shaped pelvis with a history of rickets 3. anthropoid-shaped pelvis that previously delivered a 9-lb infant 4. gynecoid-shaped pelvis with a history of poor nutrition

2. gynecoid-shaped pelvis with a history of rickets Rationale: Although the gynecoid-shaped pelvis is considered most favorable for a vaginal delivery, a woman with a history of rickets (a disease in which normal bone formation is disturbed when bone fails to mineralize and becomes soft and distorted) would be the most likely of the choices for inadequate normal vaginal delivery. An anthropoid-shaped pelvis with a history of PID, although not most favorable, allows for possible vaginal delivery, and history of PID might interfere with conception but not delivery. Previous delivery of a large infant is evidence of adequate pelvic dimensions for a normal vaginal delivery. Although poor maternal nutrition can affect the health of the newborn, delivery is not necessarily affected.

The muscular layer of the uterus that is the functional unit in pregnancy and labor is the: 1. perimetrium. 2. myometrium. 3. endometrium. 4. cervix.

2. myometrium Rationale: The myometrium is the middle muscular uterine layer and is functional in pregnancy and labor. The perimetrium is the outermost, or serosal, layer that envelops the uterus. The endometrium is the inner, or mucosal, layer that is functional during menstruation and implantation of the fertilized ovum. The cervix is the lower part of the uterus that lubricates the vagina, acts as a bacteriostatic agent, provides an alkaline environment, and produces a mucous plug.

The nurse is leading a class discussing ovulation and menstruation. The nurse explains that ovulation occurs: a. 14 days after the last menstrual period b. 14 days before the next menstrual period c. at the 16th day of a 32-day menstrual cycle d. 1 week before menses occurs 1. b and d 2. a and c 3. b only 4. d only

3

The nurse admitting a 3-year-old patient with the medical diagnosis of pneumonia identifies congestion and inspiratory wheezes in both lungs. This information is considered part of which step of the nursing process? 1. Diagnosis 2. Evaluation 3. Assessment 4. Implementation

3 Assessment involves collection of patient data.

Where is the irregular hyperpigmentation of chloasma found? 1. Chest, neck, arms, and legs 2. Breasts, areola, and nipples 3. Cheeks, forehead, and nose 4. Abdomen, breasts, and thighs

3 Chloasma is irregular hyperpigmented areas on the face.

When an expectant mother asks why she should see a physician so often during her pregnancy, what is the nurse's best response? 1. "It helps the health care facilities know how many expectant mothers are expected to deliver within the next year, as well as possible health risks." 2. "It helps hospitals know what health problems infants might have after delivery." 3. "It helps the mother to maintain good health and promote a good outcome for the fetus." 4. "It allows the doctor to screen for contagious disease that might harm the mother or fetus."

3 Promoting a good outcome for the fetus and mother is listed as one of the major goals for prenatal care.

Which is a sign of imminent birth? 1. Increased vaginal discharge 2. Baby dropping 3. Grunting sounds 4. Diarrhea

3 Sitting on one buttock, making grunting sounds, bearing down with contractions, stating "the baby is coming", and bulging of the perineum are all signs of imminent birth and the nurse should not leave the patient.

Which statement indicates that an expectant mother understands the diagnosis of placenta previa? 1. "My doctor will not let my pregnancy go beyond my due date before he induces me." 2. "My doctor will monitor for rupture of membranes each week at my appointment." 3. "My doctor will not induce labor at any time during this pregnancy." 4. "My baby will probably come early because of my condition."

3 The physician will not induce a patient with this diagnosis. Rupture of membranes is not a primary risk for this complication. This diagnosis does not have a high correlation with preterm births.

Which nursing action has the highest priority for a patient in the second stage of labor? 1. Check the fetal position. 2. Administer pain medication. 3. Help the mother push effectively. 4. Prepare the mother to breastfeed on the delivery table.

3 The second stage of labor is the pushing stage. The nurse should help the mother push effectively. The mother cannot breastfeed in the second stage of labor. Checking fetal position is not the highest priority during the second stage of labor. Pain medication should not be administered in the second stage because it will cause a lethargic neonate and possibly depress the newborn's respirations.

Which government department is responsible for overseeing the administration of the WIC program? 1. Social Security Administration 2. Department of Health and Human Services 3. Department of Public Health 4. Children's Bureau

3 This department is responsible for improving the morbidity and mortality of children.

During a prenatal clinic visit, a woman states that she probably will not plan to breastfeed her infant because she has very small breasts and believes she cannot provide adequate milk for a full-term infant. The best response of the nurse would be: 1. "Ask the physician if he or she will prescribe hormones to build up the breasts." 2. "I can provide you with exercises that will build up your breast tissue." 3. "The fluid intake of the mother will determine the milk output." 4. "The size of the breast has no relationship to the ability to produce adequate milk."

4

What is the function of Montgomery's glands? 1. Secrete lubricant into vagina for the purpose of sexual intercourse 2. Create an alkaline environment for sperm to progress into the fallopian tubes 3. Secrete milk and lubricant when stimulated by the infant when nursing 4. Secrete substances to lubricate and protect the breasts during lactation

4

When 3 to ____ cm of the fetal head is visible at the vaginal opening, this is known as crowning.

4

The physician performs a nitrazine paper test and the nurse observes the strip paper to be deep blue in color. What is the significance of this assessment? 1. The woman is at risk for placenta previa. 2. The woman is in the active phase of labor. 3. The fluid is acidic and is most likely urine. 4. The fluid is alkaline and most likely amniotic fluid.

4 A blue-green or deep blue color of the nitrazine paper indicates the fluid is alkaline and most likely amniotic fluid. A yellow to yellow-green color of the strip paper indicates the fluid is acidic and is most likely urine. The nitrazine paper test does not indicate stage of labor nor can it identify placenta previa.

A woman in labor has excess amniotic fluid. She is in active labor and is not progressing because contractions are too weak to be effective. What does the nurse suspect is the cause of this ineffective labor? 1. Ineffective maternal pushing because of fatigue 2. Increased uterine muscle tone because of oxytocin use 3. Decreased uterine muscle tone because of terbutaline use 4. Decreased uterine muscle tone because of overdistention

4 A woman with decreased uterine muscle tone has contractions that are too weak to be effective during active labor. This is more likely to occur if the uterus is overdistended, such as with twins, a large fetus, or excess amniotic fluid (hydramnios). Uterine overdistention stretches the muscle fibers and thus reduces their ability to contract effectively.

At which stage in the monthly cycle does ovulation typically occur? 1. 7 days before the end of menstruation 2. 7 days after the last day of menstruation 3. 14 days after the last day of the menstrual cycle 4. 14 days before the onset of the next menstrual cycle

4 Ovulation occurs when a mature ovum is released from the follicle, which is about 14 days before the onset of the next menstrual period.

An obstetrician informs the nurse that the patient has a laceration that extends through the anal sphincter into the rectal mucosa. Based on the definition, what does the nurse document, per the physician, as the description of this laceration? 1. First degree 2. Second degree 3. Third degree 4. Fourth degree

4 Perineal lacerations are described by the amount of tissue involved. A fourth-degree laceration extends through the anal sphincter into the rectal mucosa.

At what point does preeclampsia become eclampsia? 1. Onset of diplopia and headache 2. Blood pressure of 150/100 mm Hg or above 3. Presence of facial edema and proteinuria 4. One or more generalized tonic-clonic seizures

4 Progression to eclampsia occurs when the woman has one or more generalized tonic-clonic seizures.

At what point during the labor process does the health care provider know that the second stage of labor has begun? 1. The fetus is at +1 station. 2. The placenta is delivered. 3. The woman feels the urge to push. 4. The cervix is fully dilated at 10 cm.

4 Stage 2 is from full dilation of the cervix until birth of the fetus. Pushing before full dilation can be dangerous to the fetus and exhausting to the mother. The +1 station is too high. Delivery of the placenta is stage 3.

What is the most appropriate response from a nurse when a mother reports that her 10-year-old daughter's breasts recently began to develop and asks when her daughter might begin to menstruate? 1. "It will be several years before her menstrual cycle begins." 2. "Your daughter's menstrual cycle most likely has already started." 3. "There is no way to know when to expect her menstrual cycle to begin." 4. "The first menstrual period will most likely occur when she is around 12 years old."

4 The first menstrual period (menarche) occurs 2 to 2½ years after breast development.

Excessive anxiety and fear during labor may result in a(n): 1. ineffective labor pattern. 2. abnormal fetal presentation or position. 3. release of oxytocin from the pituitary gland. 4. rapid labor and uncontrolled birth.

ANS: 1 Anxiety can increase a woman's perception of pain and reduce her tolerance of it. Anxiety and fear also cause the secretion of stress compounds from the adrenal glands. These compounds, called catecholamines, inhibit uterine contractions and divert blood flow from the placenta.

What nursing intervention during labor can increase space in the woman's pelvis? 1. Promote adequate fluid intake. 2. Position her on the left side. 3. Assist her to take a shower. 4. Encourage regular urination.

ANS: 4 The most common soft-tissue obstruction during labor is a full bladder. The health care provider encourages urination and may catheterize a woman in labor. These interventions prevent trauma to her bladder and make more room in her pelvis.

A woman in active labor has contractions every 3 minutes lasting 60 seconds, and her uterus relaxes between contractions. The electronic fetal monitor shows the FHR reaching 90 beats/min for periods lasting 20 seconds during a uterine contraction. The appropriate priority nursing action is to: 1. continue to monitor closely. 2. administer oxygen by mask at 10 L/min. 3. notify the health care provider. 4. prepare for a cesarean section.

ANS: 1 Contractions every 3 minutes that last 60 seconds, a uterus that relaxes between contractions, and an FHR of 90 beats/minute that lasts 20 seconds during a uterine contraction all describe early decelerations, which result from compression of the fetal head and are a reassuring sign of fetal well-being.

A woman who has gestational trophoblastic disease (hydatidiform mole) should continue to receive follow-up medical care after initial treatment because: 1. choriocarcinoma sometimes occurs after initial treatment. 2. she has lower levels of immune factors and is vulnerable to infection. 3. anemia complicates most cases of hydatidiform mole. 4. permanent elevation of her blood pressure is more likely.

ANS: 1 Hydatidiform mole may cause hemorrhage, clotting abnormalities, hypertension, and later development of cancer (choriocarcinoma).

Why are twins often born early? 1. The uterus becomes overdistended. 2. The placenta becomes distended. 3. The woman's body cannot tolerate the weight. 4. The fetuses become too large to deliver vaginally.

ANS: 1 Many twin or higher multiples are born prematurely because the uterus becomes overly distended and irritable.

If a pregnant woman is admitted to the emergency department in shock after an accident, the nurse would help relieve the effect of shock by: a. placing her in Trendelenburg position b. placing her flat in bed in a supine position c. placing a small pillow under her left hip d. closely observing and documenting fetal heart rate and contractions 1. c and d 2. a and d 3. b and d 4. d only

ANS: 1 Placing a pregnant woman in supine or Trendelenburg's position places pressure on the uterine vessels and interferes with fetal circulation. Placing a small pillow under the left hip of the woman avoids this pressure. Close observation and documentation of the status of the mother and fetus is essential in all situations.

Nursing organizations that suggest standards of care in maternal-child nursing are: a. AWHONN b. ANA c. QSEN d. AAP 1. c and d 2. a and b 3. b and c 4. b and d

ANS: 1 QSEN has to do with delivering quality care; American Academy of Pediatrics (AAP) is managed by physicians who set standards for pediatric care delivered by physicians. AWHONN and ANA set standards for nursing care.

Exercise during pregnancy should be practiced to achieve which of the following goals? 1. Maintaining physical fitness 2. Minimizing weight gain 3. Achieving weight loss 4. Improving physical fitness

ANS: 1 The goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight loss.

A woman who wants to become pregnant should avoid all medications unless they are prescribed by a physician who knows she is pregnant because: 1. the placenta allows most medications to cross into the fetus. 2. medications often have adverse effects when taken during pregnancy. 3. fetal growth is likely to be slowed by many medications. 4. the pregnancy is likely to be prolonged by some medications.

ANS: 1 The thin placental membrane provides some protection, but it is not a barrier to most substances ingested by the mother. Many harmful substances such as drugs, nicotine, and viral infectious agents are transferred to the fetus and may cause fetal drug addiction, congenital anomalies, and fetal infection.

Which of the following are agencies that focus on global health and development? Select all that apply. 1. World Health Organization 2. United Nations 3. National Institutes of Health 4. American Nurses Association

ANS: 1 and 2 The NIH and ANA deal with local health issues within the United States while the WHO and United Nations deal with global health.

The health care provider gives magnesium sulfate intravenously to a woman with a diagnosis of preeclampsia. Which of the following nursing interventions are priority when caring for a patient who has received magnesium sulfate? (Select all that apply.) a. Monitor uterine tone. b. Monitor urine output. c. Keep patient NPO. d. Monitor respiratory rate. 1. a and b 2. c and d 3. b and d 4. a and c

ANS: 1, 3 (tone, urine, respiratory) Priority nursing interventions for a patient receiving magnesium sulfate for preeclampsia include monitoring uterine muscle tone to assess for complications or signs of labor, as well as monitoring urine output and respiratory rate to assess for signs of toxicity. The woman receiving magnesium sulfate can have ice chips and sips of water during treatment.

A laboring woman suddenly begins making grunting sounds and bearing down during a strong contraction. The nurse should initially: 1. leave the room to find an experienced nurse to assess the woman. 2. look at her perineum for increased bloody show or perineal bulging. 3. ask her if she needs pain medication. 4. tell her that these are common sensations in late labor.

ANS: 2 Grunting sounds and bearing down suggest that the woman is about to give birth. The nurse must stay with the woman and observe for other signs of impending birth, such as increased bloody show or perineal bulging, as well as monitor maternal and fetal well-being. The nurse may use the call bell to summon assistance or request the physician.

Select the primary difference between the symptoms of placenta previa and abruptio placentae. 1. Fetal presentation 2. Presence of pain 3. Abnormal blood clotting 4. Presence of bleeding

ANS: 2 Manifestations of placenta previa include painless vaginal bleeding that is usually bright red. Bleeding accompanied by abdominal or low back pain is a typical characteristic of abruptio placentae.

Which of the following organizations sets standards of practice for nursing? 1. American Medical Association (AMA) 2. American Nurses Association (ANA) 3. Utilization review committee 4. American Academy of Pediatrics (AAP)

ANS: 2 The ANA develops standards of practice. The AMA is a medical association that is geared toward physicians. Utilization review committee reviews appropriateness of health care services and guidelines for physicians for treatment of illness, controlling management of care to achieve cost containment. The AAP is made up of pediatricians and establishes positions of leadership in setting standards of care for children.

A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. She repeatedly asks similar questions about what happened at birth. The nurse's interpretation of the woman's behavior is that she: 1. cannot accept that she did not have the type of delivery she planned. 2. is trying to understand her experience and move on with postpartum adaptation. 3. thinks the staff is not telling her the truth about what happened at birth. 4. is confused about events because the effects of the general anesthetic are persisting.

ANS: 2 The nurse answers questions about events surrounding the birth and should encourage the woman and her partner to talk about the birthing situation so that they can integrate the experience. The focus should be on the birth rather than on the surgical aspects of cesarean delivery.

During a prenatal clinic visit, your intervention with an abused woman is successful if you have assessed the status of the woman and: 1. persuaded her to leave her abusive partner. 2. informed her of her safety options. 3. convinced her to notify the police. 4. placed her in a shelter for abused women.

ANS: 2 The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The woman should be referred to local shelters for her safety. The decision to leave her abuser is hers.

A nurse is explaining probable signs of pregnancy to a group of women. Probable signs of pregnancy include: a. fetal heart beat b. abdominal striae c. amenorrhea d. Braxton Hicks contractions 1. a and c 2. c and d 3. b and d 4. a and d

ANS: 3 Abdominal striae can be caused by stretching muscles due to weight gain and abdominal pain can be caused by gastrointestinal issues and both mistaken for signs of pregnancy. Absence of the menstrual period and the presence of a fetal heart beat are likely caused by pregnancy.

A woman is being observed in the hospital because her membranes ruptured at 30 weeks gestation. While providing morning care, the nursing student notices that the draining fluid has a strong odor. The priority nursing action is to: 1. caution the woman to remain in bed until her physician visits. 2. ask the woman if she is having any more contractions than usual. 3. take the woman's temperature; report it and the fluid odor to the RN. 4. help to prepare the woman for an immediate cesarean delivery.

ANS: 3 Amniotic fluid should be clear, possibly with flecks of vernix, and should not have a bad odor. The nurse should take the woman's temperature every 2 to 4 hours after her membranes rupture and observe, document, and report maternal temperature above 38 C (100.4 F), fetal tachycardia, tenderness over the uterine area, and foul-smelling fluid. These symptoms are suggestive of infection. A vaginal or cervical infection may cause membranes to rupture prematurely.

The nurse is caring for a woman in labor. Which of the following observations require immediate nursing intervention? a. FHR of 90 beats/min between contractions b. maternal tachysystole (excessive uterine contractions) c. contractions lasting 60 seconds with an interval of 90 seconds d. FHR baseline variability 1. b and c 2. a and d 3. a and b 4. c and d

ANS: 3 Fetal heart baseline variability is normal and contractions lasting 60 seconds with an interval of 90 seconds allow for adequate fetal circulation, and no change in nursing care is indicated. A FHR below 110 indicates fetal distress and maternal tachysystole indicates the uterine contractions are compromising fetal circulation and both require immediate intervention.

To determine the frequency of uterine contractions, the nurse should note the time from the: 1. beginning to end of the same contraction. 2. end of one contraction to the beginning of the next contraction. 3. beginning of one contraction to the beginning of the next contraction. 4. contraction's peak until the contraction begins to relax.

ANS: 3 Frequency is the time it takes from the beginning of one contraction to the beginning of the next contraction. Duration is from the beginning to the end of the same contraction. Interval is from the end of one contraction to the beginning of the next contraction.

The nurse can anticipate that which of the following patients may be scheduled for induction of labor? A woman who is: 1. 38 weeks' gestation with fetus in transverse lie. 2. 40 weeks' gestation with fetal macrosomia. 3. 40 weeks' gestation with gestational hypertension. 4. 40 weeks' gestation with a fetal prolapsed cord.

ANS: 3 Labor is induced if continuing the pregnancy is hazardous for the woman or the fetus. An indication for labor induction is gestational hypertension. Risk factors are too great for induction in the other choices.

The nurse is responsible to examine the umbilical cord of the newborn infant. The nurse knows that: a. the umbilical cord has 2 veins and 1 artery b. the umbilical cord has 2 arteries and 1 vein c. the umbilical cord has 2 arteries and 2 veins d. umbilical arteries carry blood away from the fetus e. umbilical arteries carry blood to the fetus 1. a and e 2. b and e 3. b and d 4. c and d

ANS: 3 The arteries and vein in the umbilical cord of the fetus function differently than arteries and veins in the rest of the body.

Following a vacuum extraction delivery, the nurse notices the newborn's head is not symmetrical with a chignon over the posterior fontanelle. The appropriate nursing action would be to: a. apply cold compresses to the swollen area b. notify the charge nurse or health care provider c. document and continue routine observation d. explain to the parents the swelling will resolve without treatment 1. a and b 2. a and c 3. c and d 4. all of the above

ANS: 3 The vacuum extractor causes a harmless area of circular edema on the infant's scalp (chignon) where it was applied, does not necessitate intervention, and resolves quickly.

A woman's LNMP was on April 1, 2019. She has been keeping her prenatal clinic appointments regularly but states she needs to alter the dates of a future appointment because she and her husband are going on an ocean cruise vacation for the New Year's celebration from December 30 through January 7, 2020. The best response of the nurse would be: 1. "Prenatal visits can never be altered. Every visit is important." 2. "Be sure to take antinausea medication when going on an ocean cruise." 3. "Perhaps you might consider rescheduling your vacation around the Thanksgiving holiday rather than the New Year's dates." 4. "I will reschedule your clinic appointment to accommodate your vacation plans."

ANS: 3 The woman's EDC (estimated date of confinement), using Naegele's rule, is calculated to be January 8, 2014. Scheduling a vacation that ends one day prior to the due date should be discouraged. Suggesting that the vacation be rescheduled is the best response by the nurse.

A woman who is pregnant with her first child phones an intrapartum facility and says her "water broke." The nurse should tell her to: 1. wait until she has contractions every 5 minutes for 1 hour. 2. take her temperature every 4 hours and come to the facility if it is over 38°C (100.4°F). 3. come to the facility promptly, but safely. 4. call an ambulance to bring her to the facility.

ANS: 3 When the amniotic sac ruptures, infection can become more likely if many hours elapse between the rupture of membranes and birth. In addition, the umbilical cord may slip down and become compressed. For these reasons, women should go to the birth facility when their membranes rupture, even if there are no other signs of labor.

A woman being seen for her first prenatal care appointment has a positive home pregnancy test, and her chart shows a TPALM recording of 40120. The nurse would anticipate that: 1. minimal prenatal teaching will be required because this is her fourth pregnancy. 2. the woman will need help in planning the care of her other children at home during her labor and delivery. 3. the woman should experience minimal anxiety because she is familiar with the progress of pregnancy. 4. this pregnancy will be considered high risk, and measures to reduce anxiety will be needed.

ANS: 4 According to the TPALM system, these numbers indicate that the woman has had 4 children at term, has had 0 children at preterm, has 2 children now living, and has had 0 multiples. Because it is indicated that she had 4 children at term but only 2 are living now, the system indicates this pregnancy would be high risk, and anxiety-reduction techniques will be required.

Which nursing action is the priority when a patient arrives at the clinic? 1. Prepare a plan of care. 2. Select the appropriate nursing diagnoses. 3. Administer medications as ordered. 4. Determine and document history and vital signs.

ANS: 4 Assessment is the first step of the nursing process and includes the collection of subjective and objective patient data. Diagnosis is the second step of the nursing process. Preparing a plan of care refers to the fourth step: planning. Administering medications relates to implementation, which is the fifth step of the nursing process.

During a prenatal examination at 30 weeks gestation, a woman is lying on her back on the examining table. She suddenly complains of dizziness and feeling faint. The most appropriate response of the nurse would be to: 1. reassure the woman and take measures to reduce her anxiety level. 2. offer the woman some orange juice or other rapidly absorbed form of glucose. 3. place a pillow under the woman's head. 4. turn the woman onto her side.

ANS: 4 Displacing the uterus to one side by turning the patient (preferably to the left) is all that is needed to relieve the pressure. If the woman must remain flat for any reason, then a small towel roll placed under one hip will also help prevent supine hypotension.

The nurse is providing evidence-based care when he or she: 1. adheres to hospital procedure book guidelines. 2. carries out protocols learned in nursing school. 3. carries out the practice requested by the charge nurse or health care provider. 4. knows that the practice has been published in a professional journal or text.

ANS: 4 Evidence-based practice starts when the nurse uses the best evidence obtained from current, valid, published research. When the nurse combines that information with his or her critical thinking process, experiences, and patients' needs, it is then possible to plan safe, effective nursing care for the patient. The other answer options are not accurate.

A woman arrives in the clinic for her prenatal visit. She states that she is currently 28 weeks pregnant with twins, she has a 5-year-old son who was delivered at 39 weeks gestation and a 3-year-old daughter delivered at 34 weeks gestation, and her last pregnancy terminated at 16 weeks gestation. The nurse will interpret her obstetric history as: 1. G4 T2 P2 A1 L4. 2. G3 T2 P0 A1 L2. 3. G3 T1 P1 A1 L2. 4. G4 T1 P1 A1 L2.

ANS: 4 G stands for gravida or how many pregnancies the woman has had. In this scenario there is a history of four pregnancies. The TPALM system is used to describe parity. T stands for term; this woman has had one child delivered at 39 weeks, which is considered term. P stands for preterm; this woman has had one child delivered at 34 weeks' gestation, which is considered preterm. A stands for abortion; this woman reports a pregnancy that terminated at 16 weeks' gestation. L stands for living; this woman has two living children. M stands for multiple, which is optional and not provided as a choice in this question.

The number of deaths of infants younger than 28 days of age per 1000 live births is termed the: 1. infant death rate. 2. neonatal birth rate. 3. neonatal morbidity rate. 4. neonatal mortality rate.

ANS: 4 Neonatal mortality rate is defined as the number of deaths of infants under age 1 year per 1000 live births. Birth rate and neonatal birth rate refer to the number of births per 1000 population in a year. Neonatal morbidity rate refers to illness.

The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. What action is expected based on these assessments? 1. No action is expected; the contractions are normal. 2. The rate of oxytocin administration will be increased slightly. 3. Pain medication or an epidural block will be offered. 4. Infusion of oxytocin will be stopped.

ANS: 4 Oxytocin is discontinued, or its rate reduced, if signs of fetal compromise or excessive uterine contractions occur. Excessive uterine contractions are most often evidenced by contractions closer than every 2 minutes, durations longer than 90 seconds, or resting intervals shorter than 60 seconds.

Which source would the nurse use to determine whether a specific nursing activity is within the scope of practice of an LPN/LVN? 1. Doctor's prescription record 2. Nursing procedure manual 3. Head nurse or nurse manager 4. The nurse practice act

ANS: 4 Specific activities are listed by the state nurse practice act and nurses must practice within the limitations of the nurse practice act for their state. The other answer options are not sources that determine scope of practice.

The purpose of the foramen ovale is to: 1. increase fetal blood flow to the lungs. 2. limit blood flow to the liver. 3. raise the oxygen content of fetal blood. 4. reduce blood flow to the lungs.

ANS: 4 The foramen ovale diverts most blood from the right atrium directly to the left atrium, rather than circulating it to the lungs. Therefore, blood flow to the lungs is reduced.

The child's sex is determined by the: 1. dominance of either the X or the Y chromosome. 2. number of X chromosomes in the ovum. 3. ovum, which contributes either an X or a Y chromosome. 4. sperm, which contains either an X or a Y chromosome.

ANS: 4 The ovum always contributes an X chromosome (gamete), but the sperm can carry an X or a Y chromosome (gamete).

When a couple has unprotected sexual intercourse 3 days before the woman ovulates, the risk of the woman becoming pregnant is: 1. limited because the ova lives only for 24 hours. 2. very high because both the ova and the sperm are capable of fertilizing at that time. 3. unknown. 4. very low because that is not the woman's "fertile period."

ANS: 4 The time during which fertilization can occur is brief because of the short life span of mature gametes. The ovum is estimated to survive for up to 24 hours after ovulation. The sperm remains capable of fertilizing the ovum for up to 5 days after being ejaculated into the area of the cervix. Therefore, the risk of pregnancy when unprotected intercourse occurs 4 days prior to ovulation is very low, because this is not the woman's fertile period.

A woman has an incomplete abortion followed by vacuum aspiration. She is now in the recovery room with her husband and is crying softly. Select the most appropriate nursing action. 1. Leave the couple alone except for necessary recovery-room care. 2. Tell the couple that most abortions are for the best because the infant would have been abnormal. 3. Tell the couple that spontaneous abortion is very common and does not mean that they cannot have other children. 4. Express your regret at their loss and remain nearby if they want to talk about it.

ANS: 4 The woman experiencing abortion needs the nurse to listen and acknowledge the grief she and her partner feel. Open communication techniques such as providing a quiet presence, expressing sympathy, making open-ended statements, and providing reflection can accomplish this goal.

An adolescent boy fears he is becoming incontinent because he noticed his pants are wet on occasion when he wake sup in the morning. He asks if there is a medicine to stop the problem. What is the best response by the nurse?

Educate the patient about nocturnal emissions (wet dreams) as a normal part of puberty. He should be encouraged to discuss this and other normal puberty changes to expect in the future. This facilitates communication with the adolescent and reduces the fear, embarrassment, and shame often experienced during this time.

A para 0, gravida 1 woman is admitted in active labor. She states she has completed prenatal care and wishes for a natural, unmedicated childbirth. However, she states she now does not feel she can cope with the increasing levels of pain and asks if it is okay if she takes pain medication. What is the best response of the nurse?

Giving permission for the woman to ask for medication if she believes that she needs it relieves the woman of guilt and anxiety. Analgesic agents and regional blocks are available, and the woman can still actively participate in the birth process while using those medications.

A patient is admitted to the labor unit. She has nit had any prenatal care. Her history shows that she sustained a fractured pelvis from a MVC several years ago. The patient states she is interested in natural childbirth. What is the nurses best response?

Knowing the importance of pelvic bones in determining the ability of the fetus to pass through the birth canal, the nurse would check to see if pelvic measurements had been taken. If pelvic measurements are within normal limits, natural childbirth techniques can be taught to the mother. If the pelvis healed with malformations, preparation for cesarean section may be indicated.

A 35-year-old primipara in her 20th week of pregnancy states that she does not want to drink the liquid glucose for the routine blood glucose screen because it does not taste good. She states that she is not a diabetic and does not think the test is necessary for her. What is the best response by the nurse?

The nurse explains that some women develop diabetes mellitus while pregnant, which can cause problems in the development of the growing fetus (infant). The only sign of diabetes mellitus is revealed in a glucose tolerance test. Measures can be taken to prevent problems from developing in the fetus.

A woman entering her second trimester of pregnancy states that she is noticing increasing stretch marks on her abdomen. She is afraid these marks will remain prominent after pregnancy, and she wants to go on a low-calorie diet to prevent her abdomen from becoming too large. What information should the nurse include in her teaching plan for this patient?

The nurse explains that these marks will fade after pregnancy and emphasizes the need for appropriate nutrients and a balanced diet for the well-being and development of the fetus.

A patient at 32 weeks gestation states that she wants to deliver her infant now because she feels so "big and uncomfortable." She states that she knows the infant has been fully formed since the first trimester and does not mind if it is a little small at birth. What would be the best response from the nurse?

The nurse knows maturation of systems occurs during each week of gestation. The testes descend in the last weeks, and early birth can result in medical problems, such as serious respiratory problems, for the fetus.

A patient discusses her family planning decisions. She states that she will come to the clinic for prenatal care and will begin to take prenatal vitamins as soon as she knows she is pregnant. What would be the best response from the nurse?

The nurse knows that folic acid in prenatal vitamins can prevent neural tube defects and also that neural tube development can be complete by the fourth week of gestation. Therefore, early family planning and prenatal guidance should be encouraged before the woman confirms pregnancy.