Maternity and Pedes MT
The alkaline fluids secreted by the prostate and Cowper glands serve what functions related to sperm? Select all that apply. A. Provide nourishment of the sperm B. Protect the sperm from the acidic vaginal environment C. Help mature the sperm D. Enhance sperm motility E. Cool the sperm prior to ejaculation
A, B, D
The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage? A. perineum B. cervix C. back D. birth canal
B,
A client in her first trimester is concerned about how weight gain will affect her appearance and questions the nurse concerning dietary restrictions. How much weight gain should the nurse point out will be safe for this client with a low BMI? A. 25 to 35 pounds (11 to 16 kilograms) B. 28 to 40 pounds (13 to 18 kilograms) C. 15 to 25 pounds (7 to 11 kilograms) D. 16 to 30 pounds (7.25 to 14 kilograms)
B, The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms). The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18 kilograms). Less than 28 pounds (13 kilograms) may hinder fetal development, and weight gain over 40 pounds (18 kilograms) may be dangerous to the mother. Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms). A weight gain of less than 16 pounds (7.25 kilograms) may result in a low-birth-weight infant and gains over 30 pounds (14 kilograms) may necessitate a cesarean section.
A 30-year-old woman reports that she has not had a menstrual period for the last 4 or 5 months. Pregnancy is ruled out and she is experiencing no endocrine symptoms. What factors could be contributing to her amenorrhea? Select all that apply. A. ovarian dysfunction B. working out at the gym 3 hours per day C. hypothyroidism D. endometrial adhesions E. history of chemotherapy
B,C,D
A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client? A. without a pillow B. with a pillow under her shoulders C. with a pillow under her right hip D. with a pillow under both hips
C
The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance? A. lanugo B. milia C. vernix D. amniotic fluid
C, Vernix is the coating on the infant that was covering fetal skin to prevent the skin from the drying effects of amniotic fluid. Lanugo is fine, downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. Milia are frequently found on the infant's face. These tiny white papules resemble pimples in appearance. Normal amniotic fluid is not thick and white; it should be clear and give the baby a wet appearance.
The nurse is assessing a 16-year-old female on a routine well-child visit. Which assessment finding will the nurse predict this healthy female will report concerning her menstrual cycles? A. Flow usually lasts 4 to 6 days. B. The usual cycle is 36 days. C. There's abundant clear mucus at the beginning D. Menstruation began at age 15.
A
The nurse is assessing a young female who just found out she is pregnant. She is now reporting vague abdominal discomfort. After noting the client has a history of PID, the nurse predicts the health care provider will give priority to ruling out which situation? A. Ectopic pregnancy B. Repeat PID C. UTI D. Endometriosis
A
The school nurse is preparing to illustrate the menstrual cycle to a group of high school students. Which change in the hormones will the nurse point out as being responsible for the onset of menstruation? A. Decrease in progesterone B. Increase in estrogen C. Increase in luteinizing hormone D. Decrease in follicle-stimulating hormone
A, A decrease in progesterone and estrogen during the menstrual phase is responsible for the shedding of the uterine lining, resulting in menstruation. Increases in estrogen and progesterone result in the growth of the endometrium in preparation for implantation of the fertilized ovum. An increase in luteinizing hormone will result in ovulation. An increase in follicle-stimulating hormone will result in the formation of a follicle, which results in a mature ovum being released at ovulation.
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? A. Acceleration of at least 15 bpm for 15 seconds B. Increase in variability by 27 bpm C. Deceleration followed by acceleration of 15 bpm D. Decrease in variability for 15 seconds
A, A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.
The nurse is appraising the post-birth laboratory results of a client and discovers the WBC is 22,000 cells/μL (22 x 109/L). Which action should be prioritized in response? A. none, a normal variation due to labor B. an abnormal finding, needs antibiotics C. occurs in clients after a cesarean birth D. further testing is required to determine source.
A, An elevation of WBC up to 30,000 cells/μL (30 x 109/L) can be a normal variation for any woman after birth. This is related to the stress on her body from labor and birth. Antibiotics are not indicated as this is a normal response to intense stress. The increase in WBC is not related to cesarean birth. Further testing would be wasteful as it is known that this is a normal response to any stress.
What societal issues greatly influence delivery of maternal and pediatric health care? Select all that apply. A. Cost of health care B. Increase in surrogacy and adoption C. Low income of families D. Increased cultural and ethnic diversity of clients E. Increased number of children born in the U.S.
A, C, D
A client calls the nurse in a panic after a home pregnancy test indicates she is pregnant. She reports that that she consumed a lot of alcohol on the night that she thinks the pregnancy occurred. The next day she had taken several acetaminophen. For the past 3 weeks, she has had her usual nightly glass of wine with dinner but no other alcohol. What is an appropriate response for the nurse to make when the client questions if she has caused irreversible damage to the fetus? A. "Why did you have unprotected sex if you had been drinking? Exposure to alcohol can cause facial deformities, low birth weight, and underdeveloped brains." B. "The fetus is not exposed to the mother's blood until after it implants about 6 days after fertilization, so the first night is not an issue. But it is best to avoid alcohol while you are pregnant." C. "The wedding night is not an issue because the fetus is not exposed to the mother's blood at first, but I hope this last week of drinking has not caused any problems." D. "Alcohol is very damaging to the growing fetus, so you had better be sure to stop drinking. Do you need any support for that?"
B
A client who is uncertain when her LMP occurred is given an EDD of April 23 after the first ultrasound. Based on this information, the nurse determines the client's LMP was probably which day? A. July 13 B. July 16 C. July 19 D. July 21
B
A group of nursing students are analyzing the fetal circulation. After the session, the students correctly point out which fetal structure contains the highest concentration of oxygen? A. umbilical artery B. umbilical vein C. ductus arteriosus D. pulmonary vein
B
The nurse is meeting with a client at 28 weeks' gestation. To prepare her for the final trimester, which factor should the nurse prioritize in the teaching session? A. preventing anemia B. decreasing shortness of breath C. decreasing bleeding gums D. preventing varicosities
B
A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize? A. Cerebral arteries are growing congested with blood. B. The uterus requires more blood in a supine position. C. Blood is trapped in the vena cava in a supine position. D. Sympathetic nerve responses cause dyspnea when a woman lies supine.
C
A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile? A. Travel no more than 120 miles daily. B. Sit in the back seat with feet elevated. C. Stop and walk every 2 hours. D. Limit trips away from home, greater than 200 miles.
C
The nurse is assessing a young couple who desire to get pregnant. The 38- year-old husband and 29-year-old wife report they had used oral contraceptive pills (OCPs); however, they have now been trying unsuccessfully to conceive over the past 4 months. What is the best response for the nurse to make? A. Return in 9 months for further assessment if not pregnant. B. Should seek fertility counseling from a specialist. C. Increase intercourse frequency to four times a week around the time of ovulation. D. Should undergo comprehensive diagnostic testing.
C
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? A. Notify a health care provider. B. Apply a warm washcloth. C. Place an ice pack. D. Put on a witch hazel pad.
C
The nurse is conducting a prenatal class for a group of first-time parents in the first trimester. The nurse should point out that the mother should feel the baby move by the end of which week of gestation? A. 16 weeks B. 18 weeks C. 20 weeks D. 22 weeks
C
The nurse is conducting an obstetrics assessment on a client at 20 weeks' gestation who is questioning the nurse about the development of the fetus. Which new occurring developments can the nurse point out to this client? A. Eyelids are open. B. Lungs are fully shaped. C. Eyebrows and scalp hair are present. D. A developed startle reflex is evident.
C
A married couple, both age 27, is in the reproductive clinic and have been trying for a year to become pregnant. In a year, what percentage of couples usually do conceive? A. 40 percent B. 60 percent C. 90 percent D. 100 percent
C,
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? A. Notify the RN that client's blood pressure has increased. B. Notify the RN about the lack of FHR variability. C. Help the client regain control of her breathing technique. D. Assist the client into a hands-and-knees position.
C, The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is no improvement, notify the RN. Putting the client in the hands-and-knees position should be avoided until later in labor.
A group of nursing students are preparing a presentation depicting the fetal circulation. The instructor determines the presentation is successful when the students correctly illustrate which route for the ductus arteriosus? A. The left to right heart atria B. The aorta to the pulmonary veins C. The right ventricle to the aorta D. The pulmonary artery to the aorta
D
The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse? A. spinal column movement B. shoulder movement C. clavicles for dislocation D. hip for dislocation
D
The nurse is preparing a presentation for a health fair which will illustrate the development of a baby. The nurse should point out the fertilized egg is implanted in the endometrium by which day?A. 4 B. 6 C. 8 D. 10
D
The parents are questioning why their newborn was born deaf when there are no other deaf family members. The nurse could explore possible exposure to a teratogenic agent at which stage of the pregnancy? A. 6 weeks B. at fertilization C. 12 weeks D. 18 weeks
A
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response? A. Assist the client with breathing and imagery techniques in an attempt to calm her down. B. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk. C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication. D. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
D, The nurse should first assess the client's pain by asking her to describe the pain on a scale of 0 to 10, as well as evaluate the client's actions. After the assessment, further actions can then be taken, whether that be calling the obstetrician or suggesting nonpharmacologic techniques to help the client calm down. The client should be the one to request the medication, not the spouse. The nurse should not encourage the mother's support person to leave; he or she is necessary for the psychological well-being of the mother.
The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately? A. Increment B. Acme C. Decrement D. Relaxation
D, The relaxation phase of uterine contractions is the time in which the fetus has a break. This time needs to be observed, and it is beneficial for the fetus to have a break. The three phases of a uterine contraction are the increment (building up in intensity), acme (peak intensity), and decrement (decreasing intensity). These phases are followed by a relaxation phase.
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?A. Report tachypnea. B. Recheck blood pressure in 15 minutes. C. Put warming blanket over infant. D. Document normal findings.
D, These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6 & 176;F (36.5°C to 37.5°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? A. Ambulate only with assistance from the nurse or caregiver. B. Ambulate within 15 minutes to prevent spinal headache. C. Sit on the edge of the bed with her feet dangling before ambulating. D. Remain in bed for at least 30 minutes.
A
The nurse is teaching a pregnant teenager the importance of proper nutrition and adequate weight gain throughout the pregnancy. What is the best response when the client refuses to eat due to fear of possible weight gain? ' A. The infant will be small and could have problems. B. There may be little impact on the infant, but the mother can suffer complications. C. It will just make the baby smaller, but there are no other problems associated. D. The infant will be smaller but should quickly gain weight.
A
A nurse is conducting a sexual health education class about the structures and events of semen production. Which component will the students identify as responsible for semen production if the teaching has been successful? A. accessory gland alkaline fluids B. sperm C. testes D. vas deferens E. seminiferous tubules
A, B, The alkaline fluids from the accessory glands and sperm combine to form a thick, whitish secretion termed semen or seminal fluid. The testes and seminiferous tubules within the testes are where sperm are produced. The vas deferens is the muscular tube in which sperm begin their journey out of the man's body. It connects the epididymis with the ejaculatory duct.
A client with a history of type 1 diabetes mellitus is confirmed to be pregnant. The nurse determines this client will be best cared for under which practice model? A. Case management B. The nursing process C. A clinical pathway D. A health maintenance organization
A, Case management is a system that integrates management and coordination of care with financing in an attempt to improve cost-effectiveness, use, quality, and outcomes. The nursing process involves the practice of nursing; it is not a means of cost saving for the client. The clinical pathway is a treatment regimen. HMOs are insurance organizations.
A client at 42 weeks' gestation presents for induction of labor. Which assessment should the nurse prioritize as the best indicator for the induction to proceed? A. Bishop score of 7 B. L/S ratio of 1.5 C. cervical presence of fetal fibronectin D. cervical length of 28 millimeters
A, Currently, the Bishop score of greater than 7 remains a reliable predictor of cervical readiness that is both cost- and time-effective. Measuring the cervical length by endovaginal ultrasound is another method that has been studied for predicting labor readiness; however, at this time it has not shown to be a reliable indicator of the cervix being ready for induction. At one time, it was considered to be an indicator if the cervix was 27 millimeters or less. Evaluating the fetal fibronectin is another test that has been conducted to determine cervical readiness. The presence of this protein in the cervical secretions was considered a positive sign; however, drawbacks include cost of the test and time to run the test. More studies are needed to evaluate the predictive ability of the test. The L/S (lecithin/sphingomyelin) ratio is a test conducted via amniocentesis to assess lung maturity of the fetus.
For the past 18 hours, the client has been progressing slowly in labor in spite of various attempts to encourage the labor. The health care provider decides a cesarean birth is necessary to ensure the well-being of both the mother and fetus. The nurse should point out to the client that this is due to which situation? A. dystocia B. time factor C. prevent uterine rupture D. development of infection
A, Dystocia is a general term used to describe difficult or abnormal labor. Dystocia can lead to uterine rupture or the development of an infection of the uterine membranes. The time factor is one of the criteria for the physician to determine that the client is having dystocia.
The nurse reviews the client's plan of care (above). Which nursing action(s) does the nurse identify as independent? Select all that apply.A. assisting out of bed B. administering ibuprofen C. giving IV normal saline D. reinforcing breathing exercises E. offering oral fluids
A, E
A client in latent labor for the past 12 hours is requesting medication to help her rest. The nurse predicts the health care provider will prescribe which medication? A. secobarbital B. meperidine C. fentanyl D. morphine
A, In the latent phase of labor, sedatives can be prescribed to assist a client to rest. The use of analgesics, such as opioids (meperidine, fentanyl, and morphine) in early labor may stop labor and are not recommended.
While preparing to teach a group of nursing students the history of maternity care, which factor will the instructor include to explain as the etiology of most infections in females after birthing in the 1700s? A. Reproductive tract infection B. Breast infection C. Kidney infection D. Urinary tract infection
A, Prior to the germ theory, women most often died of puerperal fever, an illness marked by high fever caused by infection of the reproductive tract after delivering infants. Women who delivered in hospitals were more likely to develop this infection than women who delivered at home. Breast infections occurred during breast feeding but were not usually fatal. There was no greater incidence of kidney or urinary tract infections.
The nurse is assessing a young couple who desire to start a family and are questioning the nurse concerning various cautions to keep in mind. Which time period should the nurse point out that teratogenics pose the greatest risk and should be avoided? A. weeks 3 to 8 B. week 9 to birth C. fertilization through week 2 D. the entire pregnancy
A, Teratogenic agents should be avoided throughout the entire pregnancy to include 3 months prior to conception. The embryonic stage (weeks 3 through 8) produces the greatest risk of damaging effects because the cells are rapidly dividing and differentiating into specific body structures. Basic structures of all major body organs and the main external features are completed during this time period, including internal organs. Week 9 to birth is the fetal stage; fertilization through week 2 is the pre-embryonic stage, and is not as concerning since the embryo is not yet connected to the mother and the chance of receiving teratogenic agents is decreased. The CNS is vulnerable throughout the entire pregnancy since it is continuously developing, and is most vulnerable during the embryonic stage
As part of the first prenatal visit, the nurse is assessing a pregnant woman's obstetrical history, which includes an 18-month-old daughter, born 2 days after her estimated date of birth; a 3-year-old son born at 35 weeks' gestation; and two lost pregnancies, one at 12 weeks and one at 21 weeks. How should the nurse document this history? A. G5 T1 P2 A1 L2 B. G4 T1 P1 A2 L2 C. G5 T2 P2 A1 L1 D. G4 T1 P2 A2 L2
A, The G represents the total number of pregnancies, which is 5. The T represents term deliveries that ended at or beyond 38 weeks' gestation, which is 1. The P refers to preterm deliveries (ended after 20 weeks and before end of 37 weeks), which is 2. The A refers to abortions or the number of pregnancies that ended before 20 weeks' gestation, which is 1. The L refers to living children, which is 2. Thus the nurse will document G5 T1 P2 A1 L2 for this client.
A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? A. Reassuring; it is associated with normal acid-base balance. B. Worrisome; it may be associated with metabolic acidosis. C. Critical; it represents metabolic acidosis. D. Damaging; it is frequently associated with fetal neurological damage.
A, The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus.
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize? A. Check the chart for the last void. B. Notify the health care provider about the mass. C. Ask the client if the mass has always been present. D. Assume this is part of the uterus.
A, The most probable explanation of the mass is a full bladder. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be handled by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? A. Use a birthing ball and find a position of comfort. B. Stay low on her back to ease the back pain. C. Use the Valsalva maneuver for effective pushing. D. Ask for privacy, and have just the partner present.
A, The position is very important during labor. Allowing the woman to assume the most comfortable position will facilitate natural birth. The birthing ball allows the woman to move and adjust her position so that she can remain comfortable. The Valsalva maneuver may result in dangerous increases in blood pressure, so the nurse should be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.
The nurse is preparing a client for treatment to ripen her cervix in anticipation of labor. When comparing the various options for the client, which one will the nurse point out possibly provides an oral option? A. misoprostol B. prostaglandin E2 gel C. dinoprostone D. prostaglandin E2 vaginal inserts
A, The synthetic prostaglandin E1 misoprostol is used off-label as a cervical ripening agent that has been successfully documented and approved by the FDA. It is administered either orally or vaginally. When given via the oral route, misoprostol causes less uterine hyperstimulation than via the vaginal route. Dinoprostone is prostaglandin E2, which can be found in a gel or vaginal inserts. The health care provider applies the gel to the cervix during the pelvic examination; this will work to ripen the cervix. The vaginal insert is a time-release product that is inserted into the vagina and will also gradually ripen the cervix. An advantage to the vaginal insert is the ability to remove the insert should adverse reactions to the prostaglandin occur.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? A. The contraction pains are 2 minutes apart and 1 minute in duration. B. The client reports back pain, and the cervix is effacing and dilating. C. The contraction pains have been present for 5 hours, and the patterns are regular. D. After walking for an hour, the contractions have not fully subsided.
B
A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy? A. Positive office pregnancy test B. Fetal movement felt by examiner C. Hegar sign D. Chadwick sign
B
A healthy client without a primary care provider is exploring the options available for a health care provider to assist with her pregnancy. Which health care provider can the nurse point out as a best option? A. Women's health nurse practitioner (NP) B. Certified nurse midwife C. Lay midwife D. Clinical nurse specialist (CNS)
B
In caring for a fully immunized pregnant woman who is a nurse in a family health practice, the obstetric nurse should remind the client that she must not come in contact with clients who have symptoms that could indicate which infection? A. measles B. Chicken pox C. smallpox D. diphtheria
B
Male and female reproductive systems are complementary; for example, male testes and female ovaries; male scrotum and female labia majora; and male glans penis and female clitoris. What part of the female system is homologous to the spermatic cord in the male? A. cardinal ligaments B. round ligaments C. uterosacral ligaments D. broad ligament
B
The nursing instructor has completed a session on the induction of labor and how it is occurring more frequently. The instructor determines the session is successful when the students correctly choose which factor to be contributing to the increased induction rates? A. increase in clients with advanced maternal age B. elective inductions by choice of both physician and client C. number of pregnancies at risk for complications D. increase in high number of multiple gestation pregnancies
B
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? A. Evolution B. Involution C. Decrement D. Progression
B
The nursing instructor is teaching a group of students about the history of maternity and family care. The instructor determines the session is successful when the students correctly choose which major change resulting from research by Klaus and Kennell? A. Limited family visits for children in the hospital B. Family-centered care of today C. Rooming-in for maternity patients D. Isolation of children with infections
B
The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick? A. "We will continue to monitor the situation." B. "The fever may be due to the epidural." C. "Have you been exposed to any illnesses recently?" D. "She's dehydrated and needs something to drink."
B, A common side effect of epidural anesthesia is elevated temperature during labor. The client needs frequent assessment and to be observed for any other signs or symptoms of an infection, but it is premature to state it is related to an infection. If the mother has been exposed to any illness, it would be in the history. Oral fluids would not be advisable as they may result in nausea later.
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic? A. This would cause fetal depression in utero. B. This may prolong labor and increase complications. C. The effects would wear off before delivery. D. This can lead to maternal hypertension.
B, Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. At this point in labor, the fetus would not be affected by analgesia. The effects would wear off and the drug would need to be re-administered, which would increase the risk to the fetus. There is no link between maternal hypertension and analgesia.
Erin, a 19-year-old first-time mother in the second stage of labor who has been given an epidural, reports severe, unrelenting abdominal pain and rates it as 10 on a scale of 0 to 10. What should the nurse do? A. Proceed with standard care; the nurse knows that this is typical in the second stage of labor and that younger women and those who are first-time mothers are more likely to report severe pain. B. Call the obstetrician; severe unrelenting abdominal pain could indicate placental abruption, uterine rupture, or other undiagnosed complication. C. Call the anesthetist, who is responsible for managing the epidural and should be monitoring Erin's pain. D. Discuss with Erin the additional pain medication options available to her at this stage in her labor so that she can choose which option she prefers.
B, After an epidural is in place, if the woman reports unrelenting pain, the provider must assess the situation for a complication. This is not a standard reaction; pain should come in waves, and should not be unrelenting. Wait for the obstetrician to page the anesthetist. Do not leave the decision up to the mother; rather, trust the experts.
The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure? A. contraction stress test B. amniocentesis C. nonstress test D. biophysical profile
B, Amniocentesis is an invasive procedure whereby a needle is inserted into the amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with Rh(D)-negative blood, since the puncture can allow the seepage of blood and amniotic fluid into the woman's system. She should receive Rho(D) immune globulin after the procedure to protect her and future babies. The CST, NST, and a biophysical profile are noninvasive tests.
A newborn infant at 36 hours of age is jaundiced. The mother is breastfeeding. What intervention is appropriate to increase the excretion of bilirubin? A. Stop breastfeeding and administer glucose water for 24 hours. B. Instruct the mom to feed every two to three hours. C. Restrict feedings and give glucose water every 4-6 hours for hydration. D. Keep the skin protected by preventing light onto the baby's skin.
B, Bilirubin is excreted in the urine and feces. Encouraging the mother to breastfeed at least every two to three hours will increase the waste and help decrease the bilirubin level. Stopping breastfeeding and administering glucose water for 24 hours would not be appropriate for the mother. Restricting feedings and giving glucose water every 4 to 6 hours is not an appropriate nursing intervention for an infant showing signs of jaundice. Keeping light away from the baby's skin does not help to clear jaundice; it could only make it worse.
A mother voices her concerns to the nurse that her daughter is an "only child" and she is worried that having no siblings may be detrimental to the child. The nurse can reassure the mother that an "only child" tends to excel in what area(s)? Select all that apply. A. Being more relaxed around others B. Advanced language development C. Intellectual achievement D. Less dependence upon the parent E. Closer identification with peers instead of parents
B, C
A community-based nurse is part of an agency sponsoring a booth at a local health fair. An acute care nurse comes up to the booth and asks the community- based nurse, "How is your practice different from practice in a hospital?" Which response(s) by the community-based nurse would be appropriate? Select all that apply. A. "In the community, we rely on other disciplines for decision-making." B. "We are more autonomous when providing client care." C. "We tend to address the client's needs more holistically." D. "Our major focus is on illness and treatment." E. "We care for clients over a longer span of time."
B, C, E
A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? A. Change in pregnancy hormone B. Body secreting the excess fluids from pregnancy C. The patient may be drinking too much fluid. D. The body is trying to get rid of the extra blood made during pregnancy.
B, Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.
The nurse is giving a newborn his first bath. What should the nurse prioritize? A. Give the sponge bath in the baby's bed. B. Wash off all traces of blood and leave the vernix in place. C. Use a soap such as hexachlorophene to prevent infection. D. Apply talcum powder to the buttocks after washing.
B, During the bath, all blood and products from the delivery need to be washed off and the vernix should be left in place to allow it to gradually absorb into the infant's body. The infant's first bath is given under a radiant warmer, not in the infant's bed. If a radiant warmer is not used, the nurse should keep the infant wrapped and expose only the part which is being washed to avoid cold stress. If soap is used at all, it is a mild soap, not a soap like hexachlorophene. No special ointments are necessary on the perineal area and buttocks after washing. Talcum powder is contraindicated because of the possibility of respiratory distress.
The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting? A. Return right away. B. Watch it and report if heavy increase in bleeding. C. The bleeding, called Chadwick sign, is a normal part of pregnancy. D. The cervical mucus plug may have been expelled.
B, During the third trimester, if the provider completes a vaginal exam it can be normal to have a small amount of spotting. If the bleeding becomes active or increases, the client needs to be seen immediately. Chadwick sign is a change of color in the vaginal area. The loss of the mucus plug would lead to a much greater amount of blood.
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? A. Immersing the client in warm water in a pool or hot tub B. Practicing effleurage on the abdomen C. Administering a sedative such as secobarbital or pentobarbital D. Administering an opioid such as meperidine or fentanyl
B, In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.Question format: Multiple Choice
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? A. Alert the team that internal fetal monitoring may be needed. B. Palpate the area just above the symphysis pubis. C. Institute effleurage and apply pressure to the client's lower back during contractions. D. Encourage the client to push.
B, Palpate just above the symphysis pubis to determine if the infant is engaged and to determine the presenting part of the infant; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.
The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age? A. 18 weeks B. 20 weeks C. 24 weeks D. 22 weeks
B, Some clients will not seek early prenatal care, especially if it is not their first pregnancy. The uterus expands to reach the height of the umbilicus by week 20. Before week 20 it is too low to be palpated, and after week 20 it may be beyond the umbilicus.
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? A. fencing B. Moro C. tonic neck D. rooting
B, The Moro reflex is also known as the startle reflex. When the infant is startled, he/she extends the arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.
The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize? A. Caution about the opioid premedication. B. Be certain she is aware of potential complications. C. Ensure she understands the need for 2 days of bed rest. D. Expect test results within 1 week.
B, The client should be aware of the potential complications and risks, and should sign an informed consent. Opioids are contraindicated for pregnant woman due to side effects. She should maintain bed rest for the remainder of the day, with light housework the following day and a return to normal activities on the third day. It may take 2 or 3 weeks before the test results come back from the laboratory.
The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started?A. Increase oral fluids B. IV fluid bolus C. Monitor temperature D. Monitor maternal apical pulse
B, The client will need to have a bolus of IV fluids prior to the epidural to prevent hypotension. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature as per routine. The nurse should monitor the radial pulse not the apical pulse.
The nurse is escorting the newborn to the transition nursery for the initial assessment and care. The nurse is prepared to carefully monitor the infant during the transition period, which occurs at which time interval? A. First 12 to 24 hours B. First 6 to 12 hours C. First 1 to 6 hours D. First 1 to 12 hours
B, The first 6 to 12 hours after birth are the critical transition hours for a newborn. The newborn may stay with the mother, but under close observation by a nurse. The newborn requires close monitoring throughout the entire period but the first 6 to 12 hours are the time when more complications may present and must be handled early to prevent long-term complications.
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? A. flexion B. engagement C. extension D. expulsion
B, The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
The client has been progressing well through the labor process and the health care provider prepares to deliver the infant and performs an episiotomy. The nurse predicts which situation is the reason for this procedure? A. prior episiotomy with last child B. shoulder dystocia C. client request so she does not tear D. previous perineal laceration with her last child
B, There is no reason to perform an episiotomy because of having had a prior one, nor because of a prior laceration with a child. Each delivery is different and the same may not be needed with this birth. The provider should not perform one on client request. The common indication is a "stuck" baby, one with shoulder dystocia or difficulty exiting due to a tight vaginal and perineal area
The client is asking the nurse about the various options for pain relief and requests more information about the intradermal water injection her sister had. When explaining the procedure, the nurse should point out these injections are given at which location? A. upper back B. lower back C. lumbar area D. iliac crest
B, This method of pain relief is considered nonpharmacologic in nature; it does not use medication to relieve the pain. Sterile water is injected under the skin to activate the gate theory of pain control. Injections are placed in the lower back in the sacral area.
A woman arrives at labor and delivery unit with contractions every 2-3 minutes lasting 30-45 seconds. After several hours of labor have passed and not making progress, the health care provider prepares to perform an amniotomy. The woman asks the nurse, "How will this help my labor?" Which response by the nurse would be appropriate? A. "This procedure helps to push your baby through the birth canal." B. "With this procedure, your body sends out hormones that make labor more effective." C. "By doing this, the passageway for your baby isn't blocked anymore." D. "The fluid that comes out helps flushes away any debris in the birth canal."
B, With an amniotomy, the health care provider guides the instrument through the cervix and uses the hook to create a hole in the membranes. At this point, amniotic fluid is usually expelled. This process causes the body to release prostaglandins, which enhances labor. An amniotomy does not open up the passageway, push the baby through the birth canal, or flush away debris.
The LPN is preparing to assist the RN with the initial admissions assessment of the newborn. The nurse should explain to the new mother that this will be completed in what time frame after birth?A. 30 minutes B. 1 hour C. 2 hours D. 4 hours
C
The nurse at a health fair is teaching about the various changes of puberty. Which sequence of events will be best for the nurse to present when illustrating pubertal changes in females? A. menarche, breast budding, appearance of pubic hair B. Appearance of pubic hair, menarche, breast budding C. breast budding, appearance of pubic hair, menarche D. appearance of pubic hair, breast budding, menarche
C
The nurse is assessing a 37-year-old woman, pregnant with twins in her second trimester, and notes the following over the past 3 visits: blood pressure 128/88, 134/90, and 130/86. Which nutritional supplement should the nurse suggest the client take? A. vitamin A B. iron C. calcium D. lactase
C
The nurse is assessing a 38-year-old Black client who has just discovered she is pregnant. On assessment, the nurse documents the client is 5 ft 10 in (1.77 m) tall and stopped using oral contraceptives 3 months ago hoping to become pregnant. Which situation may accompany her pregnancy? A. hypertension B. sickle cell anemia C. twins D. ectopic pregnancy
C
The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are? A. Normal bumps of pregnancy; they do nothing B. Might be sign of cancer; need to speak with health care provider C. Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples D. Striae, stretching of the breast tissue
C
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? A. At level of umbilicus B. 1 cm above the umbilicus C. 1 cm below the umbilicus D. At the symphysis pubis
C
The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize? A. Check the infant's temperature again. B. Complete an entire set of vital signs. C. Assess the infant's blood sugar. D. Check oxygen saturation of the blood.
C
The nurse is responding to an infant crying and notes it is very high-pitched and shrill. The nurse predicts this is most likely related to which situation? A. normal cry from pain B. tired and stress from delivery C. neurologic dysfunction D. cold stress cry
C, A high-pitched cry that is shrill is associated with a neurologic disorder. The nurse will need to inform the RN and provider to assess the infant further. A high-pitched, shrill cry in a newborn is not a normal cry from pain; it does not indicate the infant is tired and stressed from delivery, and it is not a cry indicating cold stress.
A client has moved into the active phase of labor and is now at 6 cm dilated and +1 station. The nurse is prepared to monitor the contraction pattern how often? A. Every 10 minutes B. Every 15 minutes C. Every 30 minutes D. Every hour
C, Active labor is a phase in the first stage of labor when the cervix dilates from 4 to 8 cm. The contractions are progressing and occur every 2 to 5 minutes and last 45 to 60 seconds. The nurse needs to evaluate the labor pattern every 30 minutes. During the latent phase of the first stage, the labor pattern should be evaluated every hour. During the transition phase of the first stage, the contraction pattern should also be evaluated every 30 minutes. During the second stage of labor, the contraction pattern should be evaluated every 15 minutes.
A 38-year-old client and partner are carriers of the Tay-Sachs gene, have one child with Tay-Sachs, and are concerned to learn she is pregnant again. The nurse predicts the health care provider will order which test if the couple wants to know if this baby will also be born with Tay-Sachs? A. a multiple marker screening test B. amniocentesis C. chorionic villus sampling D. percutaneous umbilical blood sampling
C, Chorionic villus sampling (CVS) is a procedure that can provide information on fetal chromosomal studies similar to an amniocentesis, but earlier in pregnancy. The CVS is typically performed between 8 and 12 weeks gestation. Multiple marker screen tests are done later in the pregnancy, as is amniocentesis. Percutaneous umbilical blood sampling examines the blood and is not the best source for chromosomal studies.
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point? A. effleurage of the abdomen during the contraction B. conscious relaxation/guided imagery in low Fowler position C. counterpressure against the sacrum D. pant-blow (breaths and puffs breathing techniques)
C, Counterpressure against the sacrum is a way to provide support and comfort for a women having intense back labor. Effleurage is ineffective for true back labor, as it is conscious relaxation. Breathing will not diminish the pain of back labor.
The nursing instructor is teaching a session on the birth process. During which stage does the woman's cardiac output increase 80% above the pre-labor level? A. first stage B. pushing C. immediately after birth D. transition stage
C, Due to an increased demand for oxygen the cardiac output increases up to 80% immediately after birth. During the first stage of labor there is a moderate increase in the demand for oxygen. While pushing, cardiac output can increase by 40% to 50%. During transition, changes are more psychological than physiologic.
A 20-year-old college student presents to the health clinic reporting fatigue, nausea, vomiting, severe abdominal cramping radiating to the lower back, and headaches. She reports these symptoms have started accompanying her menstrual cycle, which started 2 days ago. The nurse anticipates the health care provider will attempt to rule out which disorder first? A. premenstrual syndrome B. toxic shock syndrome C. secondary dysmenorrhea D. primary dysmenorrhea
C, Dysmenorrhea is painful or difficult menses. Primary refers to painful menstrual periods not associated with a disease process; secondary dysmenorrhea is related to a pelvic pathology and should be ruled out first to ensure a serious problem is not neglected but corrected as quickly as possible. PMS is a normal change in mood and physical discomfort that occurs with menstruation. Toxic shock syndrome is caused by bacterial infections.
A pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records? A. G2 T2 P1 A0 L2 B. G2 T1 P1 A1 L1 C. G3 T0 P1 A1 L2 D. G3 T2 P2 A0 L1
C, G indicates the total number of pregnancies (2 prior, now pregnant = 3); T indicates term deliveries at or beyond 38 weeks' gestation (none = 0); P is for preterm deliveries (at 20 to 37 weeks = 1; multiple fetus delivery are scored as 1); A is for abortions or pregnancies ending before 20 weeks' gestation (1); and L refers to living children which is 2. Thus, G3 T0 P1 A1 L2 is what the nurse should note in the client's record.
A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia instead of an epidural. Which medication will the nurse prepare to give the client first? A. Pain medication B. Nonsteroidal anti-inflammatory (NSAID) C. Antacid D. Sedative
C, Prior to intubation for a general surgery, the client should receive a dose of antacid to decrease the risk of aspiration of acidic stomach contents. Pain medication, NSAIDS, and sedative medications should not be given prior to a general anesthetic.
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process? A. early-stage labor B. before dilation (dilatation) only C. just before birth D. just after birth
C, Pudendal block is a local block in the perineal area and is used to numb for birth. Giving a pudendal block before labor begins or while labor is in its early stages would be counterproductive, as the client would not have proper feeling and would have a harder time pushing. After birth it is pointless; the most painful part is over.
A multigravida client at 39 weeks' gestation has been in labor for 8 hours without much change. The last vaginal exam revealed cervix 8 cm dilated and 0 station. Which is the best response if the client asks the nurse how far the fetus has advanced in the past half hour? A. "I can arrange for a cervix check, if you want." B. "The health care provider will have to check you. I'll call him." C. "Once your labor signs change, we can find out." D. "Checking your cervix will not speed up labor; let's wait."
C, The cervix must be assessed with a vaginal exam. The frequency of vaginal exams is based on the signs of changes in labor. The client has not demonstrated any changes in her labor pattern; the nurse should provide education on the reason for not checking her. Frequent exams can interfere with the labor process as well as increase the risk of infection.
A nurse is preparing a presentation on the menstrual cycle for a health fair. Which phase will the nurse illustrate as producing progesterone? A. menstrual B. proliferative C. secretory D. ischemic
C, The corpus luteum begins to produce progesterone during the secretory phase of the menstrual cycle. The follicle develops during the menstrual phase and begins to secrete estrogen. The proliferative phase continues secreting estrogen and progesterone. There are no hormones secreted during the ischemic phase, which will result in the endometrium sloughing off and leaving the uterus.
The nursing instructor is preparing a class presentation covering the various hormones and their functions during pregnancy. The instructor determines the class is successful when the class correctly matches which function with hCG? A. provides rich blood supply to decidua B. maintains nutrient-rich decidua C. continues progesterone production by corpus luteum D. sustains life of placenta
C, The corpus luteum is responsible for producing progesterone until this function is assumed by the placenta. hCG is a fail-safe mechanism to prolong the life of the corpus luteum and ensure progesterone production. Estrogen is responsible for providing a rich blood supply to the decidua. Progesterone helps maintain a nutrient-rich decidua.
The nurse is conducting a prenatal class for a group of pregnant women and their partners. When illustrating the various potential complications that can necessitate a cesarean birth, which primary reason should the nurse point out? A. placenta previa B. ruptured uterus C. nonreassuring fetal status D. preeclampsia
C, The main reasons for performing cesarean births include a history of previous cesarean or other uterine incision; labor dystocia; nonreassuring fetal status; and fetal malpresentation. Less common indications include placenta previa, ruptured uterus, and preeclampsia.
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize? A. Past obstetrical history B. Fetal status C. Signs that birth is imminent D. Client's temperature
C, The priority is to establish the imminence of the birth, then the fetal status. The obstetrical history can wait until after the birth of the baby, if necessary. The maternal blood pressure is a higher priority over the temperature to rule out possible preeclampsia.
A young couple, 8 weeks' pregnant with their first child, are being assessed at their first prenatal visit. They ask about scheduling an ultrasound to find out the gender of the fetus. For when should the nurse recommend this ultrasound be scheduled? A. for today (8 weeks' gestation) B. for 12 weeks' gestation C. for 16 weeks' gestation D. for 20 weeks' gestation
C, The sex organs can be distinguished at 12 weeks' gestation but are difficult to see on routine ultrasound. The gender of the fetus can be determined at the end of 16 weeks' gestation on ultrasound.
The nurse is preparing to teach a birthing class and intends to alert the couples to potential difficulties, ensuring they have as much accurate information as possible. Which area of the uterus will the nurse explain has the highest risk of rupture during labor? A. cervix B. corpus C. uterine isthmus D. fundus
C, The uterine isthmus is the lower uterine segment and is the thinnest portion of the uterus; it does not participate in the muscular contractions of labor. The cervix is the tubular structure that connects the vagina and the uterus. The corpus is the main body of the uterus. The fundus is the top portion of the uterus. The cervix, corpus, and fundus will all stretch and contract due to the muscular action.
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? A. Fetal station B. Fetal attitude C. Fetal position D. Fetal size
C, When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
1. Why are newborns born to diabetic mothers prone to hypoglycemia? A. Excess subcutaneous fat reduces blood flow to the tissues. B. Metabolic stress is increased due to the stress on the mother's body. C. Elevated insulin production metabolized glucose faster. D. The liver is immature and cannot convert glycogen to glucose.
C, When the mother is diabetic, she has levels of insulin and blood sugars different from a pregnant woman without diabetes. Therefore the infant/fetus develops elevated levels of insulin to combat the elevated sugars. The infant is then at risk of low blood sugar once he or she is born. Infants born to diabetic mothers do not have excess subcutaneous fat that reduces blood flow to the tissues; they do not have increased metabolic stress because of stress on the mother's body; and their immature liver is not the reason the newborn is prone to hypoglycemia.
When documenting the fetus is at "zero station", the nurse knows this is where in relation to the pelvic structure? A. Pelvic inlet B. Pelvic outlet C. Ischial spines D. Pelvic crest
C, Zero station is the engagement of the fetus at the level of the ischial spines of the pelvis. The ischial spines are a landmark that is used mark the passage of the fetus. The pelvic crest is a landmark location on the pelvis for documenting fetal station. The pelvic inlet must be shaped accordingly to allow for passage of the fetus. The pelvic outlet is associated with internal rotation of the fetal head.
The community nurse is preparing a presentation for a health fair illustrating successful pregnancies. Which component should the nurse prioritize as the most critical to ensure a positive psychological experience with the pregnancy by the mother? A. Early prenatal care B. Age at the time of pregnancy C. Having a planned pregnancy D. Social support
D
The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client? A. risk for Down syndrome B. risk for neural tube defects C. test needs to be repeated D. further testing is required
D
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron- rich foods should the nurse encourage her to add to her diet? A. Legumes B. Dairy C. Grains D. Meats
D
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth? A. "The baby is coming. Relax and everything will turn out fine." B. "Do you want me to call in your family?" C. "Even though the baby is coming, the health care provider will be here soon." D. "The baby is coming. I'll explain what's happening and guide you."
D, Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.
After discussing the various options with a pregnant client and partner, they have chosen to stay with their newborn and receive care from one nurse at the time of birth. This is referred to as which type of care? A. Regionalized care B. Maternal-child care C. Centralized care D. Couplet care
D, Couplet care is care in which the mother and child remain in the same room after labor/delivery through the postpartum period. This has become the standard of care. Regionalized or centralized care places the treatment centers in centralized locations and transfers the patient to the facility. Maternal child care allows the mother to be the primary provider of care.
The nursing instructor is teaching a group of nursing students about the menstrual cycle. The instructor determines the session is successful when the students correctly choose which action as responsible for the increased thickness of the endometrium? A. the level of the FSH B. the decreasing level of the progesterone C. the dropping level of LH D. the increasing level of estrogen
D, Estrogen levels increase after menstruation. These levels promote a thickening of the endometrial tissue. FSH and LH are responsible for ovarian changes. Progesterone will be increasing not decreasing, and works with estrogen in influencing the menstrual cycle.
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? A. Encourage the woman to rest between contractions. B. Change the woman's position. C. Give the prescribed medication. D. Massage the woman's back.
D, Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted.
The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? A. Cord compression B. Maternal hypotension C. Maternal fatigue D. Uteroplacental insufficiency
D, Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.
A young couple are disappointed that they are not yet pregnant and are seeking assistance at the health clinic. After assessing their medical history, the nurse discovers the female has a history of several episodes of PID. The nurse predicts this may be a source of the infertility related to which factor? A. It causes anovulation due to interference with secretion of pituitary hormones. B. It causes changes in cervical mucus that make it less receptive to penetration by sperm. C. It causes sperm-agglutinating antibodies to be produced in the vagina. D. It interferes with the transport of ova due to tubal scarring.
D, Pelvic inflammatory disease results in scarring and adhesions of the tubes, leading to poor transport of ova. PID does not affect hormone metabolism, nor does it affect the production of cervical mucus. Antibodies are present only in a few cases and are unrelated to PID.
The nurse is meeting with a young couple who desire to get pregnant to teach them how to determine the best times for intercourse. During which time frame should the nurse encourage them to engage in intercourse to increase their chances of getting pregnant? A. 2 days before to 1 day after ovulation B. 1 day before ovulation to 2 days after ovulation C. 3 days before or the day of ovulation D. 3 days before to 2 days after ovulation
D, Rationale: Sperm are able to live for up to 72 hours after ejaculation and the ovum remains fertile for a maximum of 48 hours after ovulation. The window of opportunity for conception is 3 days before to 2 days after ovulation.
The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation? A. achieving a maternal identity B. physical restoration and learning to care for infant C. shift in normal life to "new normal" D. beginning attachment and preparation for family
D, The first stage is the beginning attachment to the fetus and idea of a family. This occurs during pregnancy. The four stages include: 1) beginning attachment and preparation for the infant during pregnancy; 2) increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period; 3) moving toward a new normal in the first 4 months; and 4) achieving a maternal identity around 4 months.
The nurse is discussing the various positions for birth with a client and her partner. The client mentions she would like a position that speeds up the process, decreases stress to her baby, and reduces the possibility of needing an episiotomy. Which position should the nurse point out will best meet the client's desires? A. lithotomy B. modified dorsal recumbent C. side-lying D. hands and knees
D, The hands and knees position is documented to be one of the best delivery positions for easing delivery and improving outcomes. Lithotomy (feet in stirrups), modified dorsal recumbent (feet on foot pedals), and side-lying are all potential positions, but not statistically the best. They also do not meet all the goals of the client.
