Maternity and Women's Health Nursing - Women's Health
A nurse is giving discharge instructions to a client who has undergone anterior colporrhaphy. The nurse knows the teaching has been understood if the client says:
" For discomfort I can try using warm compresses on my abdomen."
A 35-year-old client is scheduled for a vaginal hysterectomy. She asks the nurse about the changes she should expect after surgery. How should the nurse respond?
"A hysterectomy doesn't affect the chronological age when menopause usually occurs."
A nurse on the postpartum unit discusses breast care with a client who is formula feeding her newborn. Which statement indicates to the nurse that more teaching is needed?
"Applying heat to my breasts will help ease the discomfort."
While teaching a prenatal class about infant feeding, the nurse is asked about the relationship between breast size and ease of breastfeeding. How should the nurse respond?
"Breast size is not related to milk production."
A client has a child with Tay-Sachs disease and wants to become pregnant again. She tells the nurse, "I'm worried it will happen again." How should the nurse respond?
"Have you considered the option of genetic counseling?"
A husband who is coaching his wife during labor demonstrates an understanding of the transition phase of labor when, as his wife starts to push with each contraction, he instructs her to:
Take quick, shallow breaths, and then blow
A primipara about to be discharged with her newborn asks the nurse many questions regarding infant care. What phase of maternal adjustment does this behavior illustrate?
Taking-hold
A woman questions the nurse about the effectiveness of oral contraceptives. What most important factor about the effectiveness of oral contraceptives should be included in the reply to this question?
User motivation
A young client tells the nurse that her mother complains about having dysmenorrhea and asks the nurse what this means. How should the nurse describe dysmenorrhea?
Uterine pain during the menstrual period
A nurse discusses the type of anesthesia that will be used for a vaginal birth with a client who has class I cardiac disease. Which type of block is most appropriate for this client?
Epidural
What is the priority nursing intervention during the 2 hours after a cesarean birth?
Evaluating the lochia to identify the complication of hemorrhage
A client with a benign ovarian tumor undergoes laparoscopic surgery. What should the nurse include in the postoperative teaching?
Expect shoulder pain for 12 to 24 hours.
A pregnant client tells the nurse that she thinks she has developed an allergy because her nose is often very congested and she has difficulty breathing. How should the nurse reply?
"That is an expected occurrence; the increased hormones are responsible for the congestion."
During a childbirth class, several participants have questions about the elective induction of labor. One participant states that it is more convenient for a woman with a busy schedule. What evidenced-based information should the nurse provide to the participant?
"The widespread use of elective induction increases the risk of unfavorable outcomes."
A postpartum client is scheduled to have a tubal ligation. She has asked that her husband not be told about the procedure because she has told him that she is having exploratory surgery. The client's husband asks the nurse why his wife needs to have exploratory surgery. How should the nurse respond?
"Have you talked to your wife about your concerns?"
A nurse teaches a client with asthma about her illness during pregnancy. Which statement by the client indicates that the nurse's teaching has been effective?
"I can use my albuterol inhaler if it's absolutely necessary."
After a mastectomy or a hysterectomy a client may feel incomplete as a woman. What statement should alert the nurse to this feeling in a client who has undergone total hysterectomy?
"I feel washed out; there isn't much left."
What statement helps the nurse determine that a woman with genital herpes (HSV-2) understands her self-care in regard to this infection?
"I must be careful when I have sex because herpes is a lifelong problem."
The nurse determines that a young female client who is being treated for a sexually transmitted infection (STI) understands instructions regarding future sexual contacts. Which statement confirms the nurse's conclusion?
"I won't have unprotected sex again, and I'll tell my partners to be tested for STIs."
After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that she and her partner are visibly upset. The partner has tears in his eyes, and the client is sobbing quietly with her face turned to the wall. At this time, what is the nurse's most therapeutic statement?
"I'll be here if you want to talk."
A nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. What client statement indicates that the teaching was effective?
"I'll notify the clinic if my lochia starts to smell bad."
Which statements by a client with hyperemesis gravidarum would confirm that the client needs further teaching? (Select all that apply.)
"I'll start limiting my carbohydrates." "I'll lie down for at least 2 hours after I eat."
After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate (Clomid) is prescribed. The nurse concludes that the client understands the teaching about the correct time to take the clomiphene when the she states:
"I'll start the pills on the fifth day of my cycle."
A nurse is instructing a client to cough and deep-breathe after an emergency cesarean birth. The client says, "Get out of here. Can't you see that I'm in pain?" Which response will be the most effective?
"If you can't cough, try taking six very deep breaths."
A client is admitted with a diagnosis of torsion of the testes. How should the nurse respond when the client asks, "Why do I have to have surgery right now?"?
"Irreversible damage occurs after a few hours."
A client seeking advice about contraception asks a nurse about how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond?
"It produces a spermicidal intrauterine environment."
A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond?
"It's all right for you to walk as long as you feel comfortable and your membranes are intact."
After an uneventful 8-hour labor a client gives birth. Once the airway has been ensured and the neonate has been dried and wrapped in a blanket, the nurse places the newborn in the mother's arms. The mother asks, "Is my baby normal?" What is the best response by the nurse?
"Let's unwrap your baby so you can see for yourself."
A client who underwent mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." What is the nurse's best response?
"Losing power seems important to you."
A nurse is teaching a woman how to perform breast self-examination. Which statement indicates that the client needs further education?
"My breasts are so tender right before my period that I hate doing it."
A nurse is teaching a prenatal class about infant safety. After the class several of the students are heard discussing what they have learned. The nurse determines that the teaching has been effective when one of the future parents states:
"My mother can't believe that babies are supposed to sleep on their backs, not their stomachs."
A female client who has been sexually active for 5 years is found to have gonorrhea. The client is upset and asks the nurse, "What can I do to keep from getting another infection in the future?" Which statement by the client indicates that the teaching by the nurse was effective?
"My partner has to use a condom all the time."
A 17-year-old client tells the nurse that her sister had an ectopic pregnancy about 3 months ago and had to have her fallopian tube removed. The nurse determines that this young woman needs additional information when she states:
"My sister is lucky, because she won't have a period again."
A client asks the nurse what she should do if she forgets to take the pill one day. How should the nurse respond?
"On the next day take one pill in the morning and one before bedtime."
A client who is scheduled for an amniocentesis says, "I'm glad that this test will show if my baby is well." How should the nurse respond?
"Potential defects caused by chromosomal errors can be detected."
A genetic counselor is working with a couple, each of whom is a carrier of an autosomal recessive disorder. Which statement indicates that the couple has understood the teaching about this disorder?
"There is a 1-in-4 chance of having a child with the disorder."
On the first day after a mastectomy, a nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. The client asks why she has to do these exercises. The best response by the nurse is:
"They will help stimulate peripheral circulation."
A client has just been informed by the health care provider that she has cervical polyps. The client asks the nurse whether she should worry about them. How should the nurse respond?
"They're usually benign, and a biopsy rules out a malignancy."
A pregnant client has a positive group B Streptoccus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan?
"This information will be in your prenatal record, but please remind your labor and delivery nurse of this finding."
A client at 37 weeks' gestation gives birth to a healthy boy. While inspecting her newborn in the birthing room, the client becomes concerned and asks, "What's this sticky white stuff all over him?" How should the nurse respond?
"This is vernix. It helps protect the baby while he's in the uterus."
A client undergoes dilation and curettage (D&C) after an early miscarriage (spontaneous abortion). The nurse finds her crying later in the day. What is the most appropriate statement by the nurse?
"This must be a very hard experience for you to deal with."
A 37-year-old woman is admitted to the unit with severe menorrhagia. During a conversation, the nurse learns that the client has a history of fibroids, menorrhagia, pelvic pain, and depression. The client has been undergoing hormone therapy in hopes of easing the symptoms and reducing fibroids' size, without success. The lab reports hemoglobin and hematocrit readings of 6.8 and 20.2, respectively. The client begins to sob and cries, "I don't know what to do — the doctor is recommending a hysterectomy, but I haven't had children yet!" What is the best response by the nurse?
"This must be so difficult for you. Children are really important to you?"
After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. What is the nurse's best response to this comment?
"This must be very difficult for you with this added pressure."
As the nurse helps a postpartum client change her perineal pad, the client comments, "I wish you didn't have to look at the pad it's embarrassing for me." What is the best nursing response?
"This seems to be uncomfortable for you, but I have to estimate the amount of blood loss to prevent any problems."
A nurse is giving discharge instructions to a new mother. What is the most important instruction to help prevent postpartum infection?
"Wash your hands before and after changing your sanitary napkins."
A client with severe preeclampsia who was admitted to the high-risk unit anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond?
"We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?"
When encouraging a client to cough and deep breathe after a bilateral mastectomy, the client says, "Leave me alone! Don't you know I'm in pain?" What is the nurse's most therapeutic response?
"What's your pain level right now?"
An older female client tells the nurse in the clinic that she has a cystocele that was diagnosed a year ago. She has urinary frequency and burning on urination. The client asks, "The doctor wanted me to have surgery for the cystocele last year, but I can manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse respond?
"Yes, you're risking kidney damage."
A multipara who is admitted to the hospital for repair of a rectocele and cystocele asks a nurse why these problems happened to her. How should the nurse respond?
"You have relaxation of the muscles in your lower pelvis."
A young woman has been using oral contraceptives. When she misses her regular menstrual period, she visits the women's health clinic and tells the nurse that she may be pregnant because she missed taking her contraceptive pills for 1 week when she had the flu. How should the nurse respond?
"You may be right. One of the reasons that an exact schedule is prescribed for birth control pills is that they have to be taken regularly to be effective."
When a client who had a mastectomy sees her incision for the first time, she exclaims, "I look horrible! Will it ever look better?" What is the nurse's best response?
"You seem shocked by the way you look now."
During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond?
"You should use foam with a condom to prevent pregnancy — this is the safest method for women with your illnesses."
A client who is scheduled to have a hysterectomy starts to sob and says, "I told my husband that after this operation, I'll be only half a woman. He told me not to worry, but I know that he was just putting up a front." How should the nurse respond?
"You think this operation will affect how your husband feels about you as his wife."
A client is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in preoperative teaching?
"You will be admitted as an outpatient for same-day surgery."
A client who is scheduled to have an abdominal panhysterectomy asks how the surgery will affect her periods. How should the nurse respond?
"You won't have any more periods."
A new mother who wishes to breastfeed her infant asks a nurse whether she needs to alter her diet. How should the nurse respond?
"You'll need extra amounts of the same foods you've been eating, plus more fluids."
A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond?
"You'll need greater amounts of the same foods you've been eating and more fluids."
A 63-year-old woman with the diagnosis of estrogen-receptor positive cancer of the breast undergoes lumpectomy and radiation therapy, and tamoxifen (Nolvadex) is prescribed. The client asks the nurse how long she will have to take the medication. The nurse responds:
"You'll need to take it for 5 years, after which it will be discontinued."
A client who is to undergo dilation and curettage, and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally?
Asking whether something is troubling the client and whether she'd like to talk about it
After the client gives birth her vital signs are temperature 99.3° F (37.4° C); pulse 80 beats/min, regular and strong; respirations 16/min, slow and even; and blood pressure 148/92 mm Hg. Which vital sign should the nurse check more frequently?
Blood pressure
A client who is visiting the family planning clinic is prescribed an oral contraceptive. As part of teaching, the nurse plans to inform the client of the possibility of:
Breakthrough bleeding
By how much should the nurse instruct a pregnant client to increase her daily protein intake?
10 g
A couple expresses a desire to use the rhythm method of birth control. The woman tells the nurse that she menstruates every 32 days. What should the nurse teach the couple about when the client's ovulation probably occurs?
14 days before the start of the next menses
A client who had a child with Tay-Sachs disease is pregnant and is to have an amniocentesis to determine whether the fetus has the disease. The nurse counsels her to plan for the procedure at the optimal time for the procedure at:
14 to 16 weeks' gestation
The nurse discusses the recommended weight gain during pregnancy with a newly pregnant client who is 5 feet 3 inches tall and weighs 125 lb. The nurse explains that with the recommended weight gain, at term the client should weigh about:
150 lb
A client who menstruates regularly every 30 days asks a nurse on what day she is most likely to ovulate. Because the client's last menses started on January 1, the nurse should tell her that ovulation should occur on which day in January?
16
A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns need about 73 mL of fluid per pound of body weight each day. In light of this information, approximately how much formula should the infant receive at each feeding?
2 to 3 oz
A primigravida in her seventh week of gestation asks the nurse when she can expect to feel her baby move. The nurse replies that quickening usually occurs in the:
20th week
A client is found to have pelvic inflammatory disease, and the health care provider prescribes intravenous cefotetan 2 g twice a day. The instructions on the vial of cefotetan say to reconstitute 20 mL of diluent to yield 1 g/10.5 mL. How much solution should the nurse add to the 100-mL bag of 0.9% sodium chloride? Record your answer using a whole number. ___ mL
21
A 30-year-old client with a 35-day menstrual cycle is trying to become pregnant. The nurse counsels the client and her partner about the optimal timing of intercourse during the cycle. The nurse determines that the counseling has been effective when the couple state that they should have intercourse on the:
21st day of the cycle
The school nurse is teaching a group of 16-year-old girls about the female reproductive system. One student asks how long after ovulation it is possible for conception to occur. The most accurate response by the nurse is based on the knowledge that an ovum is no longer viable after:
24 hours
A couple seeking genetic counseling are heterozygous carriers of Tay-Sachs disease. They ask the nurse what the chances are that each of their children will inherit the disease. The nurse responds that the probability is:
25%
A 20-year-old woman is known to be heterozygous for the cystic fibrosis (CF) gene. Her husband's genotype is unknown at present and the couple is expecting their first child. What should the nurse tell the couple about the probability of their baby's having CF?
25% or less
A client with stage 4 ovarian cancer is admitted for dehydration. The client is to receive an intravenous bolus of 500 mL D5W for 1 hour, after which the rate is to be changed to 150 mL/hr. The drop factor is 15 gtt/mL. At what rate, in drops per minute, should the nurse regulate the IV after delivery of the 500-mL bolus?
38 The nurse should administer 38 gtt/min. Solve the problem with the following formula: Total milliliters to be infused × drop factor (drops per milliliter delivered by infusion set) Total time in minutes 150 mL × 15 gtt/mL 60 minutes 2250 ÷ 60 = 37.5; round 37.5 up to 38 gtt/min. A delivery rate of 15 gtt/min is too few drops per minute, as is a rate of 25 gtt/mL. A rate of 42 gtt/mL is too many drops per minute.
A nurse in a family planning clinic determines that a client understands the discussion about using a cervical cap with a spermicide when the client states that after intercourse, a cervical cap must be left in place for at least:
6 hours
The nurse instructs a pregnant client in the sources of protein that can be used to meet the increased daily requirement during pregnancy. How many grams of protein should the client eat each day?
60 g
Which client is most at risk for osteoporosis?
A 66-year-old white woman, 5 foot 1 inch and 100 lb, who is a paralegal
What should a nurse include in the teaching plan for a couple seeking information about family planning?
A condom must be held in place by the rim when the penis is withdrawn from the vagina.
A primigravida at 8 weeks' gestation is visiting the prenatal clinic for the first time. What should an examination reveal at this time?
A primigravida at 8 weeks' gestation is visiting the prenatal clinic for the first time. What should an examination reveal at this time?
A client is scheduled for a vacuum aspiration abortion to terminate an unwanted pregnancy. What information should the nurse's teaching plan include?
A temperature of 100.4° F (38° C) or higher should be reported immediately.
A nurse is reviewing a postmenopausal client's history, which reveals that the client previously received hormonal replacement therapy (HRT) as treatment for osteoporosis. For which problem does HRT increase the client's risk?
Breast cancer
A client is admitted with a diagnosis of stage 0 cervical cancer (carcinoma in situ). What does the nurse emphasize while helping the client understand her diagnosis and prognosis?
Five-year survival rates for this cancer are nearly 100% with early treatment.
A few weeks after discharge, a postpartum client experiences mastitis and telephones for advice concerning breastfeeding. The nurse notifies the practitioner to have antibiotics prescribed. What should the nurse recommend that the client do?
Breastfeed often to keep the breasts empty.
A nurse teaches a woman who is planning to breastfeed how to relieve breast engorgement. The nurse determines that further teaching is necessary when the woman states that she will:
Breastfeed the infant less frequently
How should a nurse prepare to administer Rho(D) immune globulin (RhoGAM) to a postpartum client?
By ensuring that the client is Rh negative and the neonate is Rh positive
The day after a client has a cesarean birth, the indwelling catheter is removed. The nurse concludes that urinary function has returned when the:
Client voids 300 mL of urine within 4 hours of catheter removal
What should the nurse teach a client about performing breast self-examination?
Compress the nipples to check for discharge.
After a modified radical mastectomy a client has two portable wound drainage systems in place. What is an important intervention as the nurse cares for these drainage systems?
Compressing the drainage receptacles after emptying them to maintain suction
The clinic nurse is reviewing the dietary intake of a 16-year-old who is 12 weeks pregnant. What is the nurse's next action?
Asking the client, "How many servings of dairy do you generally consume each day?"
A client who suspects that she is 6 weeks pregnant appears mildly anxious as she is waiting for her first obstetric appointment. What symptom of mild anxiety does the nurse expect this client to experience?
Increased alertness
Four days after a vaginal hysterectomy a client calls the follow-up service and tells the nurse that she has a yellowish-green vaginal discharge. The nurse advises the client to return to the clinic for an evaluation. Which symptoms are suggestive of a vaginal infection? (Select all that apply.)
Abdominal pain Rising temperature
A 16-year-old girl who has become sexually active asks the nurse, "What's the most effective way to prevent a pregnancy?" Which method of preventing pregnancy should the nurse tell her is most effective?
Abstaining from sexual intercourse
Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication?
Active phase
At 12 weeks' gestation, a client who is Rh negative expels the total products of conception. What is the nursing action after it has been determined that she has not been previously sensitized?
Administering RhoGAM within 72 hours
The clinic nurse is planning care for a client found to have chlamydia. Which treatment should the nurse plan to implement?
Administration of azithromycin (Zithromax) 1 g orally in a single dose
A couple in their late 30s, expecting their first child, plans to have an amniocentesis. At what point in the pregnancy should the nurse tell the couple that the test it will be scheduled?
After the 14th week of pregnancy
The nurse teaches a high school sex education class that herpes genitalis infection cannot be cured but that the disease is marked by remissions and exacerbations. What else should the students be taught about this infection?
Although exacerbations occur they are not as severe as the initial episode.
The nurse is caring for a first-time mother at her first prenatal visit. The client confides, "I'm not sure about all this." Which research-based knowledge guides a nurse regarding the emotional factors of pregnancy?
Ambivalence and anxiety about mothering are common.
On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. What should the nurse explain to the couple?
An examination of semen will be needed.
Twenty-four hours after an uncomplicated labor and birth a client's complete blood count reveals a white blood cell (WBC) count of 17,000/mm3. How should the nurse interpret this WBC count?
An expected response to the process of labor and birth
After an abdominal hysterectomy the client returns to the unit with an indwelling catheter. The nurse notes that the urine in the client's collection bag has become increasingly sanguineous. What complication does the nurse suspect?
An incisional nick in the bladder
A client elects to have her pregnancy terminated after finding out at 16 weeks' gestation that she is carrying a fetus with Down syndrome. What should the nurse conclude about an abortion at this stage of the pregnancy?
An opportunity for the client to express feelings about her decision should be provided.
A husband sits in the waiting room while his wife is getting her infertility prescription refilled by the clinic pharmacist. As the nurse sits down beside him, he blurts, "It's like there are three of us in bed—my wife, me, and the doctor." What feeling is reflected by this statement?
Anger
A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? (Select all that apply.)
Apply cool packs to her breasts to reduce the discomfort Take the analgesic medication prescribed to limit the discomfort Assume a different position when breastfeeding to adjust the infant's sucking
A client with a third-degree uterine prolapse is scheduled for a vaginoplasty. What should the nurse anticipate the surgeon will prescribe?
Apply moist compresses to the uterine prolapse.
One statement by a breastfeeding mother that indicates that the nurse's teaching about stimulating the let-down reflex has been successful is "I will:
Apply warm packs and massage my breasts before each feeding."
On the third postpartum day a client who is breastfeeding calls the clinic complaining of hot, hard, aching breasts. What recommendation should the nurse include in the response?
Apply warm, moist cloths to both breasts before nursing.
At her first prenatal clinic visit a primigravida has blood drawn for a rubella antibody screening test, and the results are positive. What intervention is important when the nurse discusses this finding with the client?
Asking her whether she has had German measles and when she had the disease
A client comes to the clinic for a 6-week postpartum checkup. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information?
Asking the client questions, using a postpartum depression scale
Which client care activity may a nurse safely delegate to a nursing assistant?
Assisting a client who is recovering from an abdominal hysterectomy to the bathroom
In the second hour after a client gives birth, her uterus is found to be firm, above the level of the umbilicus, and to the right of midline. What is the appropriate nursing intervention at this time?
Assisting the client to the bathroom to empty her bladder
A primigravida complains of morning sickness. What should the nurse plan to teach her?
Avoid long periods without food
During the discharge conference with a client who has had a hysterectomy the nurse includes instructions for avoiding the thromboembolic phenomena that may occur as a complication. What should these instructions include?
Avoid sitting for long periods of time.
A woman has made the decision to have breast augmentation surgery, and the procedure is to be performed on an outpatient basis. As part of the preoperative protocol, the nurse provides teaching regarding the discharge instructions. Which instructions apply to this type of surgery? (Select all that apply.)
Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief. Sleep with your head and torso elevated for at least 1 week. Take your temperature daily and notify the clinic if it goes above 99.6° F.
A primigravida tells the nurse that she has morning sickness. What suggestion should the nurse make to help relieve the nausea?
Avoiding long periods without food
A client has a total hysterectomy with bilateral salpingo-oophorectomy for cancer of the ovary. In addition to encouraging ambulation, what exercise should the nurse instruct the client to perform to help prevent postoperative deep vein thrombosis (DVT)?
B
A nurse is counseling a pregnant client with iron-deficiency anemia about when and how to take supplemental iron. What time of day and with what drink is iron absorption most efficient?
Before breakfast with orange juice
A client seeking family planning information asks the nurse during which phase of the menstrual cycle an intrauterine device (IUD) should be inserted. Before responding the nurse recalls that the insertion usually is done:
Between the first and fourth days of the cycle
When a client is being given an intravenous infusion of magnesium sulfate, the nurse should have its antidote readily available. Which of the following medications would the nurse administer if toxicity were to occur?
Calcium gluconate
Which behavior indicates to a nurse that a new mother is in the taking-hold phase?
Calling the baby by name
A client has just been told that she has cervical erosion. The nurse would expect to help explain that early treatment of the erosion can help prevent:
Cancer of the cervix
A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? (Select all that apply.)
Cardiac output increases. Blood pressure decreases. The heart is displaced upward.
A nurse is caring for a client with tertiary syphilis. Which body system should the nurse monitor most closely?
Cardiovascular
A neonate is born with exstrophy of the bladder, and the parents are upset. They are told that corrective surgery will be performed as soon as possible. How can the nurse best help the parents at this time?
Caring for the newborn in the same manner as any other newborn
The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? (Select all that apply.)
Carrots Sweet potatoes
A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing can cause which of the following?
Cervical edema
An estrogen-progestin oral contraceptive is prescribed for a client. Which adverse effects should the nurse teach the client to report to the health care provider? (Select all that apply.)
Chest pain Breast soreness Calf tenderness
In childbirth classes the nurse is teaching paced breathing techniques for use during labor. In which order should the breathing techniques be used as labor progresses?
Cleansing breaths, in which the woman breathes in through the nose and out through the mouth, are used at the beginning and end of each contraction. Slow, deep breaths are used early in the first stage of labor to promote relaxation of abdominal muscles. Modified paced breathing may be used when the woman can no longer walk or talk through contractions; it requires concentration and promotes relaxation and oxygenation. As contractions increase in frequency and intensity, more complex breathing techniques require enhanced concentration and therefore block painful stimuli more effectively. Patterned, paced breathing, such as pant-blow, is used during the transition phase of the first stage of labor. Slow exhalation pushing is used during the second stage to facilitate a controlled birth, minimizing maternal trauma and the need for an episiotomy.
A client who has just had a cesarean birth is receiving IV fluids and has an indwelling catheter. The client's fluid intake will need to be increased when the nurse identifies:
Dark amber urine
A 24-year-old client complains to the nurse in the women's health clinic that her breasts become tender before her menstrual period. What should the nurse recommend that the client do 1 week before an expected menses?
Decrease caffeine intake
A client's temperature is 100.4° F 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature?
Dehydration
A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the health care provider to prescribe?
Dexamethasone
A nurse is counseling a client with type 1 diabetes who has requested contraceptive information. On which method of contraception should the nurse place the most emphasis?
Diaphragm
What is the safest and most reliable birth control method for the nurse to recommend to a client with type 1 diabetes?
Diaphragm with a spermicidal gel
A nurse in the fertility clinic is instructing a client who will be using progesterone gel vaginally in the treatment of luteal phase infertility. When discussing the side effects of progesterone, what should the nurse tell the client to expect?
Enlarged, tender breasts
A client undergoes anterior and posterior surgical repair of a cystocele and rectocele and returns from the postanesthesia care unit with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? (Select all that apply.)
Discomfort is minimized. Retention of urine is prevented. Pressure on the suture line is relieved.
A client at 16 weeks' gestation arrives at the prenatal clinic for a routine visit. During the examination the nurse notes bruises on the client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm:
Domestic abuse
The nurse discusses fetal weight gain with a pregnant client. When does it usually show a marked increase?
During the third trimester
A woman visits the clinic because she has dysmenorrhea. What goal should the nurse identify for this client?
Easing the pain of the client's menstruation.
A client had a fourth-degree perineal laceration during the birth of her neonate. What should the nurse recommend to protect the area from additional trauma?
Eat a high-fiber diet with increased fluid intake.
A client is receiving antibiotics and antifungal medications for the treatment of a recurring vaginal infection. What should the nurse encourage the client to do to compensate for the effect of these medications?
Eat yogurt daily
What should the nurse emphasize in a class about childbirth?
Education; exercise, and breathing techniques
The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will first be heard with:
Electronic Doppler ultrasonography at 10 to 12 weeks
A 47-year-old client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse that she has been experiencing hot flashes and that her periods have been occurring at longer, less regular intervals, with a scanty flow. What does the nurse conclude is the most likely cause of these changes?
Expected menopausal changes
When discussing future health management with a client who has had a total hysterectomy, the nurse advises regular physical examinations. The client agrees and adds, "It won't be so hard to go now that I won't need the pelvic examination and Pap smear." How should the nurse respond?
Explain why regular pelvic examinations and Pap smears of vaginal secretions will be necessary in the future.
What is the best nursing intervention to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination?
Explaining the procedure and maintaining eye contact while touching the client gently
A resident practitioner in the birthing unit asks the nurse to prepare for a vaginal examination on a client with a low-lying placenta who is in early labor. What is the priority nursing action?
Explaining why a vaginal examination should not be performed
A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What should the informed consent include? (Select all that apply.)
Explanation of available alternative treatments Answers to questions and concerns about the procedure Complete description of the possible dangers and discomforts
A nurse in the fertility clinic works with couples who have been trying to become pregnant for more than 1 year. How can the nurse help ease the feeling of isolation that infertile couples often experience?
Explore ways to promote communication with family and friends
A client's nipples become sore and tender as a result of her newborn's vigorous suckling. What should the nurse recommend that the mother do to alleviate the soreness? (Select all that apply.)
Expose the nipples to air several times a day. Apply hydrogel pads to the nipples after each feeding.
Which risk factors are associated with the future development of osteoporosis in women? (Select all that apply.)
Familial predisposition Cigarette smoking Inadequate intake of dietary calcium
A couple in their late 30s who wish to have a child are referred for genetic counseling. They tell the nurse that they have a family history of an inheritable problem but have reservations about genetic counseling because they believe that genetic clinics favor abortion when the studies reveal a defective fetus. How should the nurse respond regarding genetic counseling?
Families are helped to understand the diagnosis, the probable cause of the disorder, and how the condition can be managed.
A breastfeeding mother asks the nurse how human milk compares with cow's milk. How should the nurse respond?
Fat in human milk is easier to digest and absorb than the fat in cow's milk.
During a class for prepared childbirth, the nurse teacher discusses the importance of the spurt of energy that occurs before labor. Why is it important to conserve this energy?
Fatigue may influence pain medication requirements.
A nurse is planning care for a client who gave birth to a preterm male infant. What most common response does the nurse anticipate that the mother may experience?
Feelings of failure and loss of control
A nurse is observing the electronic fetal monitor as a client in labor enters the second stage. The nurse identifies early decelerations of the fetal heart rate with a return to the baseline at the end of each contraction. What does this usually indicate?
Fetal head compression
A pregnant client who is scheduled for a nonstress test (NST) asks a nurse how the test can show that "my baby is all right." The nurse explains that it is a way of evaluating the condition of the fetus by comparing the fetal heart rate (FHR) with:
Fetal physical activity
A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? (Select all that apply.)
Focus on and repeat a rhythmic chant. Eat small, frequent meals and eat dry crackers in between.
A nurse evaluates that a client who is taking oral contraceptives understands the related dietary teaching when the client states, "While I'm taking birth control pills I should increase my intake of foods containing:
Folic acid."
The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. What resting position should be recommended by the nurse?
Fowler
A client who is pregnant for the first time and carrying twins is scheduled for a cesarean birth. What should preoperative teaching include?
Frequent ambulation is begun within 24 hours.
A primigravida, unsure of the date of her last menstrual period, is told by the nurse that she appears to be at 22 weeks' gestation. What data support this conclusion?
Fundus at the umbilicus
A nurse is obtaining a health history from a primigravida on her first visit to the prenatal clinic. Before discussing the client's health habits with her, what does the nurse consider the most important factor in the survival of the client's newborn?
Gestational age and birthweight
The nurse is caring for a group of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage?
Giving birth to a baby weighing 9 lb 8 oz
A married 35-year-old client is to undergo a tubal ligation. The factor in the history that contributes most to the healthy resolution of any emotional problem associated with sterilization is that the client:
Has a son and daughter and feels that her family is complete
The husband of a woman who had her fourth child 3 weeks ago states she has been irritable and crying frequently since bringing her newborn home. He asks the nurse whether this is normal. The nurse tries to help him understand the situation by stating that:
Having four children is tiring and assistance may be needed.
The nurse is teaching a prenatal breathing and relaxation class. What does the nurse suggest to best ease back discomfort during labor?
Having support persons use back massage techniques
A nurse is teaching a female client about using oral contraceptives and when to report complications. What clinical findings should alert the client to stop taking the contraceptive and notify the health care provider immediately? (Select all that apply.)
Headaches Visual disturbances
During the fourth stage of labor, the assessment of a primipara who has had a vaginal birth reveals a moderate to large amount of lochia rubra, a firm fundus that is at the umbilicus and deviated to the right, and pain that she rates as a 3 on a scale of 1 to 10. What is the priority nursing action?
Helping the client void
A primipara delivered 12 hours ago. Although an ice bag has been applied to her perineal area, the client continues to complain of rectal pressure resulting in excruciating pain in the area of the episiotomy that is not relieved with analgesics. What does the nurse conclude is the cause of the client's pain?
Hematoma in the perineal area
A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? (Select all that apply.)
Hemorrhage Increased temperature
A client presents to the clinic with complaints of nausea and amenorrhea and reports that she obtained a positive result on a home pregnancy test. Which component of the history is most indicative of pregnancy?
Her urine immunoassay test is positive,
A 31-year-old client is seeking contraceptive information. Before responding to the client's questions about contraceptives, the nurse obtains a health history. What factor in the client's history indicates to the nurse that oral contraceptives are contraindicated?
History of borderline hypertension
A primigravida at 12 weeks' gestation complains of nausea and vomiting during a visit to the prenatal clinic. Which pregnancy hormone should the nurse explain is thought to be responsible for nausea and vomiting during the first trimester?
Human chorionic gonadotropin (hCG)
A nurse is caring for four clients, each with a different medical condition. Which condition should the nurse anticipate will result in the client's being instructed by the health care provider not to breastfeed?
Human immunodeficiency virus
A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. What condition does the nurse suspect the client is experiencing?
Hydatidiform mole
A client making her first visit to the prenatal clinic asks which immunization can be administered safely to a pregnant woman. What should the nurse tell her?
Inactive influenza
A client who wishes to postpone having children until she and her husband are financially sound tells the nurse she has been taking oral contraceptive pills for several years. What finding indicates a potential risk in regard to continued use of birth control pills?
Increased blood pressure
A client at 10 weeks' gestation phones the prenatal clinic to report that she is experiencing some vaginal bleeding and abdominal cramping. The nurse arranges for her to go to the local hospital. The vaginal examination reveals that her cervix is dilated 2 cm. What diagnosis should the nurse expect?
Inevitable abortion
A pregnant client with an infection tells the nurse that she has taken tetracycline (Tetracyn) for infections on other occasions and prefers to take it now. The nurse tells the client that tetracycline is avoided in the treatment of infections in pregnant women because it:
Influences the fetus's teeth buds
A client arrives at the fertility clinic for a diagnostic workup and is told by the nurse to prepare for a Papanicolaou (Pap) test. The client states, "I do not want this test. I want to speak to the person in charge." How should the nurse respond to this statement?
Inform the health care provider of the client's request
A nurse is interviewing a female client with a tentative diagnosis of cystitis pending laboratory results. The nurse anticipates that the causative agent of the cystitis is Escherichia coli. The nurse anticipates this microorganism because it:
Inhabits the intestinal tract
A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting HIV. What should the nurse advise her to do?
Insist that her partner use a condom when having sex
A thin older adult client is found to have osteoporosis. What should the nurse include in the discharge plan for this client?
Instructions relative to diet and exercise
A nurse has learned that infants born to very young mothers are at risk for neglect or abuse primarily because an adolescent characteristically:
Is involved in seeking her own identity
A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. What does the nurse identify as the main reason that this medication is administered?
It acts as an anticonvulsant.
A nurse is writing a teaching plan about osteoporosis. How should the nurse explain what osteoporosis is?
It involves a decrease in bone substance.
A pregnant client interested in childbirth education asks how the Lamaze method differs from the Read method. What should the nurse explain about the Lamaze method?
It provides relaxation and techniques that can be used during labor.
A pregnant woman asks the nurse when she may expect her baby to be born. She tells the nurse that her last menstrual period began on April 14. According to Nägele's rule, what is the client's expected date of birth (EDB)?
January 21 To use Nägele's rule to calculate the EDB, subtract 3 months and add 7 days to the date of the last menstrual period.
A client has a modified radical mastectomy because of a malignant tumor of the breast. What does the nurse plan to teach the client during the early postoperative period?
Keep the arm in an elevated position.
What nursing action best promotes parent-infant attachment behaviors?
Keeping the new family together immediately after the birth
A pregnant couple is attending preparation-for-childbirth classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor?
Kegel exercises
A woman is admitted for a hysterectomy and bilateral salpingo-oophorectomy. The nurse reviews the client's gynecological history. What condition does the client have that causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy?
Large uterine fibroids
A client is scheduled to have a contraction stress test (CST) to determine fetal well-being. Which type of fetal heart rate (FHR) decelerations constitutes a nonreassuring outcome?
Late
What factor identified by the nurse in a client's history places the client at increased risk for breast cancer?
Late beginning of childbearing
A 23-year-old woman comes to the clinic for a Pap smear. After the examination, the client confides that her mother died of endometrial cancer 1 year ago and says that she is afraid that she will die of the same cancer. Which risk factor stated by the client after an education session on risk factors indicates that further teaching is needed?
Late-onset menarche
A client in preterm labor is to receive a tocolytic medication, and bedrest is prescribed. Which position should the nurse suggest that the client maintain while on bedrest?
Lateral
A client with cervical cancer is to undergo a course of internal radiation. The client returns to her lead-lined room on the oncology unit with an indwelling urinary catheter and a vaginal applicator in place. Once the practitioner has loaded the applicator with the radiation source, the nurse's plan of care should include:
Leaving the urinary catheter undisturbed
A nurse is caring for a client in labor whose cervix is dilated 6 cm. The client is receiving epidural analgesia. What common response to regional anesthesia does the nurse anticipate?
Lightheadedness
What nursing care is required for a client with a radium implant for cancer of the cervix?
Limiting the client's activity to avoid dislodging the radium insert
A nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. What changes does the nurse explain result from the melanocyte-stimulating hormone? (Select all that apply.)
Linea nigra Chloasma
A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter (OTC) medicine now that she is past the first 3 months of pregnancy. The nurse explains why she should consult with her health care provider before taking any oral medications. What physiological alteration associated with pregnancy may change the client's response to medication?
Longer gastrointestinal emptying time
A 30-year-old woman is to undergo total abdominal hysterectomy for noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. What is the most common reason for this difficulty?
Loss of femininity
A nurse is caring for a client with vaginal bleeding caused by placenta previa. What is the best nursing intervention to delay the birth of the fetus?
Maintaining bed rest
During discharge teaching a client who just had a hysterectomy states, "After this surgery, I don't expect to be interested in sex anymore." What should the nurse consider before responding?
Many women incorrectly equate hysterectomy with loss of libido.
Thirty minutes after a client gives birth, the nurse palpates the client's uterus. It is relaxed and the lochia is excessive. What is the nurse's initial action?
Massage the uterus
One hour postpartum a nurse evaluates the amount of vaginal bleeding and determines that a client's uterus has become relaxed and boggy. What should the nurse do next?
Massage the uterus until firm
During a childbirth class the nurse determines that the women understand how to use effleurage correctly when they are observed:
Massaging their abdomens gently with their fingertips
A pregnant client is experiencing nausea and vomiting. The nurse determines that this discomfort:
May be related to an increased human chorionic gonadotropin level
A client comes to the fertility clinic for hysterosalpingography using radiopaque contrast material to determine whether her fallopian tubes are patent. When preparing for the test, the nurse explains to the client that she:
May have some persistent shoulder pain for 14 hours after the test
The day after a hysterectomy, the client asks for sanitary pads because she feels that she is going to menstruate. What information should influence the nurse's response?
Menstruation will not occur because the uterus has been removed.
A nurse is caring for a client who has contracted a trichomonal infection. Which oral drug should the nurse anticipate that the health care provider will most likely prescribe?
Metronidazole (Flagyl)
The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? (Select all that apply.)
Metrorrhagia Bowel strictures Voiding difficulties
A nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which foods identified by the client indicate that the teaching is effective? (Select all that apply.)
Milk Eggs Cheese
During a routine prenatal office visit at 26 weeks' gestation, a client states that she is getting fat all over and that she even needed to buy bigger shoes. What is the next nursing action?
Obtaining the client's weight and blood pressure
A client attending the prenatal clinic for the first time tells the nurse that her last menstrual period began on January 11 and that she suspects that she is pregnant. The client also states that she had one day of light spotting on February 7. What is the expected date of birth (EDB)?
October 18
A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? (Select all that apply.)
Nesting needs increase. Anxiety about childbirth increases. Gastrointestinal motility decreases.
The nurse teaches a pregnant client why she needs a folic acid supplement. Which neonatal disorder does folic acid prevent?
Neural tube defects
A nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning discharge accompanied by a burning sensation and lower abdominal pain. After an examination the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she has been sexually active and asks the nurse whether her parents will be contacted. The nurse explains that her parents will:
Not be contacted, because treatment at the clinic is confidential
A female client is scheduled for a hysterectomy. While discussing the preoperative preparations, the nurse determines that the client's understanding of the surgery is inadequate. What is the next nursing intervention?
Notifying the surgeon that the client needs more information
At a client's first visit to the prenatal clinic, the nurse asks the client when she had her last menstrual period so the estimated date of birth (EDB) can be determined. The client responds, "January 21." According to Nägele's rule, what is the month and day of the client's EDB?
October 28
A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply?
Open neural tube defects
Contraceptives that contain estrogen-like and/or progesterone-like compounds are prepared in a variety of forms. Which contraceptives should the nurse tell clients have a hormonal component? (Select all that apply.)
Oral drugs Transdermal agents
A female client with Hodgkin's disease is to start chemotherapy. She and her husband have been trying to have a child and are quite concerned when they learn that sterility may result. On what information should the nurse base the reply?
Ova can be harvested and frozen for future use.
A 37-year-old client with endometriosis visits the women's health clinic because she has dysmenorrhea and dyspareunia. What is a description of dysmenorrhea?
Pain with menses
A nurse is assessing a client who is being admitted for surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? (Select all that apply.)
Painful intercourse Bearing-down sensations
The nurse presents a program on breast self-examination. After a return demonstration the nurse concludes that she needs to review certain aspects of the teaching program. Which behavior by one of the students supports this conclusion?
Palpating each breast while in the sitting position
A mother is concerned that her newborn will be exposed to communicable diseases when she goes home. While teaching the mother ways to decrease the risk of Infection; what type of immunity should the nurse explain was transferred to her baby through the placenta?
Passive natural
Methods of relieving back pain are explained during a childbirth class. What activities identified by the client permit the nurse to conclude that the teaching has been understood? (Select all that apply.)
Pelvic rocking Forward tilting Sacral pressure
A nurse is caring for several new mothers in the birthing unit, all in the taking-in phase of the postpartum period. What information is most appropriate for these clients at this time?
Perineal care
The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is:
Perineal care
A client with a large fetus is to have a pudendal block during the second stage of labor. What does the nurse plan to instruct the client about the effectiveness of the block? (Select all that apply.)
Perineal pain will not be felt. The bearing-down reflex will be diminished.
The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day?
Pinkish brown
A strict vegetarian (vegan) becomes pregnant and asks the nurse whether there is anything special she should do in regard to her diet during pregnancy. What is most the important measure for the nurse to instruct the client to take?
Plan to eat from specific groups of vegetable proteins each day.
A pregnant client asks a nurse for information about toxoplasmosis during pregnancy. What should the nurse teach the client about how to prevent the transmission of toxoplasmosis?
Pork and beef should be cooked well before being eaten.
A nurse discusses herpes genitalis as part of a high school sex education program. The nurse explains to the students that herpes genitalis is:
Responsible for local as well as systemic reactions
Which factor in a client's history increases the risk for osteoporosis?
Prolonged immobility
A client in her 30th week of gestation is in preterm labor, and the practitioner prescribes betamethasone (Celestone). The client asks the nurse why she is being given this drug. As a basis for the response the nurse takes into consideration that it:
Promotes neonatal pulmonary maturity
A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time?
Promotion of maternal and fetal well-being during labor
What antidote to the side effects of terbutaline (Brethine) should a nurse have available?
Propranolol (Inderal)
A nurse is teaching a breastfeeding client about medications that are safe and unsafe for her to take. Which medication is contraindicated?
Propylthiouracil (PTU)
A nurse is teaching a class of expectant parents about nutritional needs during pregnancy. What information should the nurse include?
Protein needs increase to at least 70 g/day during pregnancy.
A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including that the client will understand with regard to active immunity?
Protein substances are formed by the body to destroy or neutralize antigens.
Which action involving client needs may a nurse delegate to a nursing assistant?
Providing ice chips to a primigravida in early labor per order
A client in preterm labor is receiving subcutaneous terbutaline (Brethine) tocolytic therapy. The nursing action that is most important during the initial administration of this medication is assessing the client's:
Pulse rate continuously
A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? (Select all that apply.)
Raw shellfish Herbal supplements Soft-scrambled eggs
At a routine monthly visit, while assessing a client who is in her 26th week of gestation, the nurse identifies the presence of striae gravidarum. The nurse describes this condition as:
Reddish streaks on the abdomen and breasts
A nurse is counseling a pregnant client who is a vegetarian. What should the nurse plan to do to ensure optimal nutrition during the pregnancy?
Refer the client to a dietitian to help plan her daily menu
A fetal monitor is applied to a client in labor. The nurse should take action in response to a fetal heart rate that:
Repeatedly drops abruptly to 90 beats/min unrelated to contractions
A client who recently gave birth is transferred to the postpartum unit by the nurse. What must the nurse do first to avoid a charge of abandonment?
Report the client's condition to the responsible staff member
Rho(D) immune globulin (RhoGAM) is prescribed for an Rh-negative client who has just given birth. Before giving the medication, the nurse verifies the newborn's Rh factor and reaction to the Coombs test. Which combination of newborn Rh factor and Coombs test result confirms the need to give Rho(D) immune globulin ?
Rh positive with a negative Coombs result
Before the administration of Rho(D) immune globulin (RhoGAM) the nurse reviews the laboratory data of a pregnant client. Which blood type and Coombs test result must a pregnant woman have to receive RhoGAM after giving birth?
Rh-negative and Coombs negative
A client asks the nurse about the use of an intrauterine device (IUD) for contraception. What information should the nurse include in the response? (Select all that apply.)
Risk for perforation of the uterus Expulsion of the device Occasional dyspareunia
A nurse is preparing a client with a ruptured tubal pregnancy for immediate surgery. What type of surgery should the informed consent include?
Salpingectomy
A client appears at the clinic after getting a positive result on a home pregnancy test. She states that her last menstrual period began 10 weeks ago. The client expresses fear because she has been recently found to have syphilis. What prescriptions will the nurse expect to receive from the health care provider because of this information? (Select all that apply.)
Screening and testing of sexual partners Intramuscular benzathine penicillin G, 2.4 million units, one dose
A 36-year-old client undergoes a modified radical mastectomy. The nurse determines that the client understands the schedule for self-examination of her remaining breast when she states that she will examine her breast:
Seven days after each menstrual period
When teaching a client about using a diaphragm as a form of contraception, the nurse should tell her that the diaphragm:
Should remain in place for at least 6 hours after intercourse
A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. (Select all that apply.)
Sleep needs increase. Fluid retention increases. Calcium requirements increase.
What does the nurse teach a client to do when performing breast self-examination?
Squeeze the nipples to examine for discharge
A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant?
Start taking prenatal vitamins
A client states that she wishes to use the calendar method of birth control. The nurse concludes that the client understands how to calculate the beginning of the fertile period when she states, "I will:
Subtract 18 days from the length of my shortest cycle"
A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. What aspect of the client's life is most important for the nurse to explore at this time?
Support system
A nurse is planning care with a client for the recovery period after a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What should be included among the changes that the client should expect after surgery?
Surgical menopause
A nurse is evaluating a client's understanding regarding postoperative concerns after mastectomy. Which development near and around the incision noted by the client should be reported to her practitioner?
Swelling with erythema
The nurse is teaching a sex education course to high school students. What should the nurse teach them about why gonorrhea is difficult to control? (Select all that apply.)
Symptoms of the disease are vague. The incubation period is relatively short. Causative organisms have become resistant to treatment.
After an emergency cesarean birth, the client tells the nurse that she was hoping for a "natural" childbirth but is glad that she and her baby are all right." Which postpartum phase of adjustment does this statement most closely typify?
Taking-in
An adolescent who gave birth one day ago confides to the nurse that she hopes that her baby will be good and sleep through the night. What should the nurse include in the plan of care to facilitate a realistic expectation of a nighttime newborn schedule?
Talk softly and cuddle the baby when crying occurs
A nurse is caring for an adolescent in labor an hour after she was admitted to the birthing unit. The adolescent is anxious and tense. She cries during contractions and asks the nurse for epidural anesthesia. The nurse obtains the adolescent's current vital signs and reviews her history and admission information. What nursing interventions are essential before epidural anesthesia is administered? (Select all that apply.)
Telling the adolescent what to expect with each procedure Identifying risk factors that contraindicate epidural anesthesia Performing a baseline vaginal examination
A nurse is teaching a childbirth preparation class about the discomfort of labor. What is the greatest influence on the perception of pain for a woman in labor?
Tension of the client
Laboratory studies reveal that a pregnant client's blood type is O, and she is Rh positive. The client asks whether her newborn will have a problem with blood incompatibility. Before responding, the nurse must remember that fetal problems may develop if the fetus is:
Type A or B
A nurse is caring for a client who is being given intravenous magnesium sulfate to treat preeclampsia. Which adverse side effect alerts the nurse to notify the health care provider?
Urine output of less than 100 mL in 4 hours
A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program?
The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary
A client who has had a mastectomy asks what the term ERP-positive means. How should the nurse explain this finding?
The tumor cells generally exhibit a positive response to hormone therapy that reduces estrogen.
A nurse caring for a pregnant client and her partner suspects domestic violence. Which observations support this suspicion? (Select all that apply.)
The woman has injuries to the breasts and abdomen. The partner answers questions that are asked of the woman. The woman has visited the clinic several times in the last month.
A couple at the prenatal clinic for a first visit tells the nurse that their 2-year-old child has just been found to have cystic fibrosis. They state there is no family history of this disorder. They ask the nurse about the chances of their having another child with cystic fibrosis. Knowing that this disorder has an autosomal recessive mode of inheritance, how should the nurse respond?
There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier.
The nurse reads the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as gravida 1 para 1 before the baby was born. How should the nurse use these data to gather more information?
To consider that someone recorded the gravida and para incorrectly
A client at 16 weeks' gestation is scheduled for a sonogram followed by amniocentesis. The nurse instructs the client to drink 8 oz of fluid and not void before the sonogram. The nurse explains that this is done:
To improve visualization of the fetus
The healthcare provider of a woman who had a mastectomy has prescribed a Reach to Recovery visit. What does the nurse identify as the primary reason for the referral?
To prevent social isolation
A woman arrives at the prenatal clinic stating that her pregnancy test is positive. She asks the nurse for information about an abortion. After verifying that the woman is at 8 weeks' gestation, the nurse counsels her that having an abortion is controversial and that many women have long-lasting feelings of guilt after an abortion. What is the nurse's legal responsibility?
To provide the client with correct, unbiased information
A nurse is teaching a client how to self-administer a medicated douche. In which direction should the nurse instruct the client to direct the douche nozzle?
Toward the sacrum
When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. What should the nurse teach the client?
Treat constipation when it occurs and continue drinking milk.
A client with osteoporosis has been receiving dietary information from the nurse. Which food selection by the client indicates that the nurse's dietary instruction was effective?
Turnip greens
A client who is taking an oral contraceptive calls the nurse with concerns about side effects of the medication. Which adverse effect of this medication should alert the nurse to inform the client to immediately stop the contraceptive and contact the health care provider? (Select all that apply.)
Visual disturbances Persistent headaches
A nurse instructs a client who is taking oral contraceptives to increase her intake of dietary supplements. Which supplement should be increased?
Vitamin C
A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet?
Vitamins A, C, and E and selenium
A nurse is teaching a breastfeeding mother about cleansing her nipples. What technique should the nurse emphasize?
Wash the breasts and nipples with water when bathing.
What should the nurse teach a formula-feeding mother about breast engorgement when it occurs?
Wear a tightly fitted brassiere.
A client with endometriosis asks the nurse what side effects to expect from leuprolide (Lupron). What should the nurse include in the response?
Weight gain
What client behavior indicates to the nurse that a woman needs further teaching about breastfeeding her newborn?
When she leans forward to place her breast in the infant's mouth
A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain?
Whether an earlier tuberculin test's result was positive
A client attending a prenatal class about nutrition tells the nurse that she is a strict vegetarian (vegan). What should the nurse encourage the client to eat that includes all the essential amino acids?
Whole-grain cereals and nuts
What is most important information to teach to a client who has had a mastectomy before she leaves the hospital?
Why self-examination of the remaining breast is important
When seeing her preterm infant son in the neonatal intensive care unit for the first time, a mother exclaims, "He's so little! How will I ever be able to take care of him?" The nurse explains to the mother that she:
Will be encouraged to participate in his care as much as possible
A nurse at a women's health clinic confirms that client teaching regarding the use of an oral contraceptive is understood when the client states, "I:
Will put a baby's picture on my bathroom mirror so I'll see it every morning"
A client is admitted in preterm labor. After intravenous tocolytic medications are administered, contractions cease and she is discharged. She is to receive oral terbutaline (Brethine) 5 mg every 6 hours at home. When should the nurse advise the client to take the medication?
With food
The partner of a woman experiencing back pain in labor asks what he can do to help. The nurse demonstrates how to apply counterpressure to his partner's back. Where on the image should counterpressure be applied?
d
