Maternity Final #2

In utero, what is the organ responsible for gas exchange? 1. Umbilical vein 2. Placenta 3. Inferior vena cava 4. Right atrium

Answer: 2 Explanation: 2. In utero, the placenta is the organ of gas exchange.

Dystocia encompasses many problems in labor. What is the most common? 1. Meconium-stained amniotic fluid 2. Dysfunctional uterine contractions 3. Cessation of contractions 4. Changes in the fetal heart rate

Answer: 2 Explanation: 2. The most common problem is dysfunctional (or uncoordinated) uterine contractions that result in a prolongation of labor.

Intercourse is contraindicated if the pregnancy is vulnerable because of which diagnosis? 1. Gestational diabetes 2. Cervical insufficiency (cerclage) 3. Abruptio placentae 4. Placenta previa

Answer: 3 Explanation: 3. As the uterus enlarges, the couple will have to experiment with different positions.

Which of the following is a major side effect of butorphanol tartrate (Stadol)? 1. Blurred vision 2. Agitation 3. Feelings of dysphoria 4. Drowsiness

Answer: 3 Explanation: 3. Feelings of dysphoria are a major side effect of Stardol.

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? 1. Occasional watery stools 2. Spitting up after feeding 3. Jitteriness and irritability 4. Nasal stuffiness

Answer: 3 Explanation: 3. Jitteriness and irritability can be an indicator of drug withdrawal.

The student nurse encounters a 15-year-old girl who reports that she has no pubic or axillary hair and has not yet experienced growth of her breasts. The student asks the nurse about the physiology of this occurrence. The nurse explains that the client probably lacks which hormone? 1. Testosterone 2. Progesterone 3. Estrogen 4. Prolactin

Answer: 3 Explanation: 3. Estrogens influence the development of secondary sex characteristics.

If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent what? 1. The potential for hemorrhage 2. Hyperhomocysteinemia 3. Antibody formation 4. Tubal pregnancy

Answer: 3 Explanation: 3. If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent antibody formation.

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature? 1. Every hour 2. Every 2 hours 3. Every 4 hours 4. Every shift

Answer: 3 Explanation: 3. Maternal temperature is taken every 4 hours unless it is above 37.5°C. If elevated, it is taken every hour.

The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about? 1. Postpartum psychosis 2. Postpartum infection 3. Postpartum depression 4. Postpartum blues

Answer: 3 Explanation: 3. Postpartum depression can impair maternal-infant bonding and can cause developmental and cognitive delays in the child.

Which of the following diagnostic tests would the nurse question when ordered for a client diagnosed with pelvic inflammatory disease (PID)? 1. CBC (complete blood count) with differential 2. Venereal Disease Research Laboratory (VDRL) 3. Throat culture for Streptococcus A 4. RPR (Rapid Plasma Reagin)

Answer: 3 Explanation: 3. Streptococcus of the throat is not associated with PID.

) The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? 1. 60 breaths per minute 2. 70 breaths per minute 3. 64 breaths per minute 4. 20 breaths per minute

Answer: 4 Explanation: 4. If respirations drop below 20 when the baby is at rest the primary care provider should be notified.

The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? 1. Otoscopic exam of the eardrum 2. Bowel sounds 3. Vital signs 4. Skin assessment

Answer: 1 Explanation: 1. Infants who bottle feed in a supine position have an increased risk of otitis media and dental caries in the older infant.

Which of the following is a common barbiturate used in labor? 1. Seconal 2. Valium 3. Phenergan 4. Vistaril

1. Seconal

The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician? 1. Excretion of less than 300 mg of protein in a 24-hour period 2. Platelet count of less than 100,000/mm3 3. Urine output of 50 mL per hour 4. 12 respirations

: 2 Explanation: 2. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 100,000/mm3).

A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority? 1. Fluid Volume: Deficient 2. Cardiac Output, Decreased 3. Injury, Risk for 4. Nutrition, Imbalanced: Less than Body Requirements

Answer: 1 Explanation: 1. The newly admitted client with hyperemesis gravidarum has been experiencing excessive vomiting, and is in a fluid volume-deficit state.

The nurse notes the following findings in a client at 12-weeks' gestation. Which of the findings would enable the nurse to tell the client that she is diagnostically pregnant? 1. Fetal heart rate by Doppler 2. Positive pregnancy test 3. Positive Chadwicks sign 4. Montgomery gland enlargement

Answer: 1 Explanation: 1. A fetal heart rate by Doppler is a diagnostic (positive) change of pregnancy.

The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? 1. Hyperventilation 2. Seizure auras 3. Imminent birth 4. Anxiety

Answer: 1 Explanation: 1. These symptoms all are consistent with hyperventilation.

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, nasal flaring 4. 4-hour-old female who has not voided

Explanation: 3. Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress.

Which client requires immediate intervention by the labor and delivery nurse? 1. Client at 8 cm, systolic blood pressure has increased 35 mm Hg 2. Client who delivered 1 hour ago with WBC of 50,000 3. Client at 5 cm with a respiratory rate of 22 between contractions 4. Client in active labor with polyuria

: 2 Explanation: 2. The white blood cell (WBC) count increases to 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification.

What interventions would the nurse apply to support the breastfeeding mother? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assist the mother to begin breastfeeding within the first hour after birth. 2. Have the baby returned to the nursery after feeding so that the mother can get adequate rest. 3. Teach the mother to recognize and respond to early infant feeding cues. 4. Inform the mother about community resources that support breastfeeding. 5. Instruct the mother to avoid eating foods that might upset the newborn's stomach

1, 3, 4 Explanation: 1. Throughout the first 2 hours after birth, but especially during the first hour of life, most infants are usually alert and ready to breastfeed. 3. The new mother should be taught to recognize and respond to early infant feeding cues. The timing of newborn feedings is ideally determined by physiologic and behavioral cues rather than a set schedule. 4. It is important that parents receive verbal and written instructions and community resource information to which they can later refer.

A primary herpes simplex infection in the first trimester can increase the risk of which of the following? 1. Spontaneous abortion 2. Preterm labor 3. Intrauterine growth restriction 4. Neonatal infection

Answer: 1 Explanation: 1. A primary herpes simplex infection can increase the risk of spontaneous abortion when infection occurs in the first trimester.

During a home visit, a new mother who is breastfeeding complains that her nipples are sore and cracked. Which measures should the nurse suggest? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Alternate the baby's nursing positions throughout the day. 2. Breastfeed the baby always in a seated position 3. Avoid placing the areola in the baby's mouth. 4. Insert a finger between the infant's gums to break the latch before removing from the breast. 5. Wash the breasts with warm water, and avoid drying soaps.

1, 4, 5 Explanation: 1. Changing positions alters the focus of greatest stress and promotes more complete emptying of the breasts. 4. To prevent trauma, the mother should also be taught to gently insert her finger between the infant's gums to break the latch before removing the baby from the breast. 5. The nurse can instruct the mother in a number of measures to promote comfort and healing and to prevent skin breakdown. Washing the breasts with warm water and avoiding drying soaps are recommended

To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which type of medication? 1. Antacids 2. Tranquilizers 3. Antihypertensives 4. Anticonvulsants

Answer: 1 Explanation: 1. Antacids are routinely administered before surgery for a cesarean section.

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. Previous birth by cesarean 2. Frank breech ballotable 3. 37 weeks, complete breech 4. Failed ECV last week

Answer: 1 Explanation: 1. Any previous uterine scar is a contraindication to ECV. Prior scarring of the uterus may increase the risk of uterine tearing or uterine rupture.

A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what? 1. Sodium 2. Carbohydrates 3. Protein 4. Fruits

: 3 Explanation: 3. The client who experiences preeclampsia is losing protein.

A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Confirm fetal heart activity. 2. Evaluate the cervix. 3. Determine fetal presentation. 4. Amniotic fluid volume. 5. Fetal number.

: 3, 4, 5 Explanation: 3. A standard ultrasound examination is performed during the second or third trimester and includes an evaluation to determine fetal presentation. 4. A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of amniotic fluid volume. 5. A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of fetal number.

The nurse is assessing a client who is at 35 weeks' gestation. What does the nurse expect the client to report at this phase of pregnancy? 1. Nausea and vomiting 2. Maternal ambivalence 3. Emotional shifts from highs to lows 4. Stretch marks on the abdomen

Answer: 4 Explanation: 4. Striae are purplish stretch marks that may develop as the pregnancy progresses.

A 27-year-old married woman is 16 weeks pregnant and has an abnormally low maternal serum alpha-fetoprotein test. Which statement indicates that the couple understands the implications of this test result? 1. "We have decided to have an abortion if this baby has Down syndrome." 2. "If we hadn't had this test, we wouldn't have to worry about this baby." 3. "I'll eat plenty of dark green leafy vegetables until I have the ultrasound." 4. "The ultrasound should be normal because I'm under the age of 35."

Answer: 1 Explanation: 1. A low maternal serum alpha-fetoprotein test can indicate trisomy 18 or trisomy 21 (Down syndrome). Many couples abort a fetus that has a genetic abnormality that significantly affects quality of life or has multiple medical problems. Down syndrome is more likely to occur in the fetuses of women over the age of 35 at delivery, but is not limited to this age group.

The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? 1. Weak 2. Mild 3. Moderate 4. Strong

Answer: 4 Explanation: 4. Strong intensity exists when the uterine wall cannot be indented.

In evaluating information taught about conception and fetal development, the client verbalizes understanding about transportation time of the zygote through the fallopian tube and into the cavity of the uterus with which statement? 1. "It will take at least 3 days for the egg to reach the uterus." 2. "It will take 8 days for the egg to reach the uterus." 3. "It will only take 12 hours for the egg to go through the fallopian tube." 4. "It will take 18 hours for the fertilized egg to implant in the uterus."

Answer: 1 Explanation: 1. "It will take at least 3 days for the egg to reach the uterus" is the correct statement.

Which client in the gynecology clinic should the nurse see first? 1. 22-year-old with fever, hypotensive, using tampons 2. 15-year-old, no menses for past 4 months 3. 18-year-old seeking information on contraception methods 4. 31-year-old, reports increasing dyspareunia

Answer: 1 Explanation: 1. A client using tampons who has a fever, is dizzy, and hypotensive might have toxic shock syndrome.

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? 1. The infant's mother has group B streptococcal (GBS) disease. 2. The infant's mother had an IV of lactated Ringer's solution. 3. The infant's mother had a labor that lasted 12 hours. 4. The infant's mother had a cesarean birth with her last child.

Answer: 1 Explanation: 1. A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis.

The postpartum homecare nurse has performed home visits to four breastfeeding mothers. Which mother is experiencing an expected outcome? 1. Breasts are engorged; placing fresh cabbage leaves inside her bra 2. Sore and cracked nipples; using hydrogel dressings to facilitate healing 3. Breast engorgement; accompanied by erythema 4. Concerns about milk supply; supplementing with formula

Answer: 1 Explanation: 1. A compress of fresh green cabbage leaves helps reduce engorgement.

) The prenatal clinic nurse is explaining test results to a client who has had an assessment for fetal well-being. Which statement indicates that the client understands the test result? 1. "The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby." 2. "The reactive non-stress test means that my baby is not growing because of a lack of oxygen." 3. "Because my contraction stress test was positive, we know that my baby will tolerate labor well." 4. "My biophysical profile score of 6 points to everything being normal and healthy for my baby."

Answer: 1 Explanation: 1. A decrease in fetal cardiac output or an increase in resistance of placental vessels will reduce umbilical artery blood flow. Doppler velocimetry is best used when intrauterine growth restriction is diagnosed; therefore, the baby is getting an adequate blood supply.

A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be? 1. Perform a vaginal exam. 2. Notify the physician. 3. Place the client in a left lateral position. 4. Administer oxygen at 2 L per nasal cannula.

Answer: 1 Explanation: 1. A drop in fetal heart rate accompanied by variable decelerations is consistent with a prolapsed cord. The nurse would assess for prolapsed cord via vaginal examination.

A cesarean section is ordered for a pregnant client. Because the client is to receive general anesthesia, what is the primary danger with which the nurse is concerned? 1. Fetal depression 2. Vomiting 3. Maternal depression 4. Uterine relaxation

Answer: 1 Explanation: 1. A primary danger of general anesthesia is fetal depression. The depression in the fetus is directly proportional to the depth and duration of the anesthesia.

The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old woman at 39 weeks' gestation with a large-for-gestational-age (LGA) fetus 2. 22-year-old woman at 23 weeks' gestation with ruptured membranes 3. 30-year-old woman at 41 weeks' gestation and estimated fetal weight 7 pounds 8 ounces 4. 43-year-old woman at 37 weeks' gestation with hypertension

Answer: 1 Explanation: 1. A risk factor for hypotonic uterine contraction patterns includes a large-for-gestational-age (LGA) fetus.

A client and her husband have contacted their physician about fertility problems. At the initial visit, the nurse instructs them about the infertility workup. Which statement by the client would indicate that the instructions have been successful? 1. "The first test that we need to schedule is a semen analysis." 2. "We need to schedule the Pap smear test first." 3. "We need to schedule an appointment with the social worker in order to adopt." 4. "We need to schedule an appointment with a marriage counselor."

Answer: 1 Explanation: 1. A semen analysis is one of the first diagnostic tests, prior to doing invasive procedures.

The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? 1. A shift of intracellular water to extracellular spaces. 2. Loss of meconium stool. 3. A shift of extracellular water to intracellular spaces. 4. The sleep-wake cycle.

Answer: 1 Explanation: 1. A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss.

How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? 1. Breech, transverse 2. Breech, longitudinal 3. Breech, frank 4. Vertex, transverse

Answer: 1 Explanation: 1. A shoulder presentation is one type of breech presentation, and is also called a transverse lie.

The client's Pap smear result is ASC-US. Which statement is the best way for the nurse to explain this ASC-US result? 1. "Abnormal squamous cells of undetermined significance." 2. "Cancer has invaded the upper cervix." 3. "High-grade squamous intraepithelial lesion (HSIL), which includes CIN." 4. "The focus of the Pap smear is the detection of high-risk pregnancy." 5. "The cervical cells are abnormal and the reason why is severe dysplasia and carcinoma in situ."

Answer: 1 Explanation: 1. ASC-US stands for abnormal squamous cells of undetermined significance. Preferred management is HPV testing; if positive, refer for colposcopy; if negative, repeat HPV co-testing in 3 years.

Abdominal hysterectomy is generally recommended for which condition? 1. Severe endometriosis 2. Removal of the ovaries 3. Suspected or confirmed cancer removal 4. Abnormal uterine bleeding

Answer: 1 Explanation: 1. Abdominal hysterectomy is recommended for severe endometriosis.

The 12-year-old client reports that menarche occurred 5 months ago. She has had bleeding every day this month, and is very worried. The nurse should explain that the most common cause of this bleeding is which of the following? 1. Dysfunctional uterine bleeding (DUB) 2. Diabetes mellitus (DM) 3. Pregnancy 4. Von Willebrand's disease

Answer: 1 Explanation: 1. Adolescents often experience DUB during the first 2 years following menarche due to hypothalamic immaturity after menarche.

Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye

Answer: 1 Explanation: 1. After administration, the nurse massages the eyelid gently to distribute the ointment.

The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? 1. "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." 2. "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." 3. "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." 4. "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families."

Answer: 1 Explanation: 1. Although it is true that some cultures believe colostrum to be unhealthy, colostrum helps to protect the infant from disease and illness.

The nurse is preparing a client for amniocentesis. Which statement would indicate that the client clearly understands the risks of an amniocentesis? 1. "I might go into labor early." 2. "It could produce a congenital defect in my baby." 3. "Actually, there are no real risks to this procedure." 4. "The test could stunt my baby's growth."

Answer: 1 Explanation: 1. Amniocentesis has the potential for causing a spontaneous abortion.

The pregnant client and her partner are both 40 years old. The nurse is explaining the options of chorionic villus sampling (CVS) and amniocentesis for genetic testing. The nurse should correct the client if she makes which statement? 1. "Amniocentesis results are available sooner than CVS results are." 2. "CVS carries a higher risk of limb abnormalities." 3. "Amniocentesis cannot detect a neural tube defect." 4. "CVS is performed through my belly or my cervix."

Answer: 1 Explanation: 1. Amniocentesis results take longer to process than do CVS results.

The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? 1. Specially prepared formulas 2. Cataract problems 3. Low glucose concentrations 4. Administration of thyroid medication

Answer: 1 Explanation: 1. An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Lofenalac, Minafen, and Albumaid XP, are available.

The nurse has completed a community presentation about the changes of pregnancy, and knows that the lesson was successful when a community member states that which of the following is one probable or objective change of pregnancy? 1. "Enlargement of the uterus" 2. "Hearing the baby's heart rate" 3. "Increased urinary frequency" 4. "Nausea and vomiting"

Answer: 1 Explanation: 1. An examiner can perceive the objective (probable) changes that occur in pregnancy. Enlargement of the uterus is a probable change.

A couple is requesting fertility counseling. The nurse practitioner has identified the factors listed below in the woman's health history, and knows which of them could be contributing to the couple's infertility? 1. The client is 38 years old. 2. The client was 13 years old when she started her menses. 3. The client works as a dental hygienist 3 days a week. 4. The client jogs 2 miles a day.

Answer: 1 Explanation: 1. As the eggs of older women age, their fertility is reduced.

The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? 1. Purulent, foul-smelling lochia 2. Decreased blood pressure 3. Flank pain 4. Breast is hot and swollen

Answer: 1 Explanation: 1. Assessment findings consistent with endometritis are foul-smelling lochia, fever, uterine tenderness on palpation, lower abdominal pain, tachycardia, and chills.

) The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? 1. "My baby isn't getting enough iron from my breast milk." 2. "Babies undergo physiologic anemia of infancy." 3. "This results from dilution because of the increased plasma volume." 4. "Delaying the cord clamping did not cause this to happen."

Answer: 1 Explanation: 1. At 2 months of age, infants increase their plasma volume, which results in physiologic anemia. This condition is not related to iron in the breast milk.

Babies should sleep in what position every time they are put down for sleep? 1. On their backs 2. On their stomachs 3. On their left sides 4. On their right sides

Answer: 1 Explanation: 1. Babies should sleep on their backs every time they are put down for sleep.

A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the client understands that what is essential? 1. That she not become pregnant until after the follow-up program is completed 2. That she receive RhoGAM with her next pregnancy and birth 3. That she has her blood pressure checked weekly for the next 30 days 4. That she seek genetic counseling with her partner before the next pregnancy

Answer: 1 Explanation: 1. Because of the risk of choriocarcinoma, the woman treated for hydatidiform mole should receive extensive follow-up therapy. Follow-up care includes a baseline chest X-ray to detect lung metastasis and a physical examination including a pelvic examination. The woman should avoid pregnancy during this time because the elevated hCG levels associated with pregnancy would cause confusion as to whether cancer had developed.

The home health nurse is visiting a new mother whose baby was delivered by emergency cesarean after a car accident. The mother seems dazed, irritable, and unaware of her surroundings. She tells the nurse she has had trouble sleeping. What would the nurse suspect that the mother has? 1. Post-traumatic stress disorder 2. Postpartum blues 3. Postpartum psychosis 4. Disenfranchised grief

Answer: 1 Explanation: 1. Because of the traumatic nature of the birth and the client's symptoms, this condition is most likely post-traumatic stress disorder (PTSD). At particular risk for PTSD are women who have histories of prior trauma and/or prior psychiatric histories and women who undergo emergency cesarean sections.

The nurse is scheduling an ultrasound for a 51-year-old client with a suspected uterine tumor. The nurse includes in the client's teaching that the most common benign uterine tumor seen in women in their 50s is which of the following? 1. Fibroid tumor 2. Fibroadenoma 3. Fibrocystic tumor 4. Lymphoma

Answer: 1 Explanation: 1. By the age of 50, 70% of Caucasian women and 80% of African American women have fibroids.

At her first prenatal visit, a woman is discussing fetal development with the nurse. The client asks, "When will my baby actually have a heartbeat?" The nurse should say the heartbeat of an embryo is distinguishable by what time? 1. "The fourth week" 2. "The sixth week" 3. "The eighth week" 4. "The twelfth week"

Answer: 1 Explanation: 1. By the end of the fourth week, embryonic blood is circulating between the embryo and the chorionic villi.

A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilatation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? 1. Cervical dilatation 6 cm 2. Mild contraction intensity 3. Contraction frequency every 5 minutes 4. Contraction duration 30-40 seconds

Answer: 1 Explanation: 1. Cervical dilatation of 6 cm indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 cm and contractions and pain intensify.

The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? 1. "Cesarean birth after extended labor with ruptured membranes." 2. "Unassisted childbirth and afterbirth." 3. "External fetal monitoring used throughout labor." 4. "The client has history of pregnancy-induced hypertension."

Answer: 1 Explanation: 1. Cesarean birth is the single most significant risk of postpartum endometritis as well as prolonged premature rupture of the amniotic membranes (PPROM).

What type of testing is an inexpensive way to predict the presence of tubal disease and may be more predictive of infertility than an abnormal HSG? 1. Chlamydia trachomatis IgG antibody testing 2. Preimplantation genetic testing 3. Noninvasive prenatal testing (NIPT) 4. DNA testing

Answer: 1 Explanation: 1. Chlamydia trachomatis IgG antibody testing is an inexpensive way to predict the presence of tubal disease and may be more predictive of infertility than an abnormal HSG.

During a prenatal exam, a client describes several psychosomatic symptoms and has several vague complaints. What could these behaviors indicate? 1. Abuse 2. Mental illness 3. Depression 4. Nothing, they are normal

Answer: 1 Explanation: 1. Chronic psychosomatic symptoms and vague complaints can be indicators of abuse.

A pregnant client at 24 weeks' gestation is diagnosed with bacterial vaginosis. Her doctor orders Flagyl to treat the problem. What would be appropriate education for the nurse to provide? 1. The client must be careful to observe for signs of preterm labor. 2. The client should advise her partner to seek therapy as soon as possible. 3. The main side effect of the medication is a large amount of vaginal discharge. 4. A repeat culture should be taken 2 weeks after completing the therapy.

Answer: 1 Explanation: 1. Clients with bacterial vaginosis are at risk for preterm labor.

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? 1. Fewer infants require blood transfusion for anemia 2. Fewer infants require blood transfusion for high blood pressure 3. Increase in the incidence of intraventricular hemorrhage 4. Increase in incidence of infant breastfeeding

Answer: 1 Explanation: 1. Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for anemia.

Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism? 1. Complement 2. Coagulation 3. Inflammatory response 4. Phagocytosis

Answer: 1 Explanation: 1. Complement helps or "complements" the ability of antibodies and phagocytic cells to clear pathogens from an organism.

A laboring client's obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response? 1. Contractions elicited are similar to those of spontaneous labor. 2. Amniotomy decreases the chances of a prolapsed cord. 3. Amniotomy reduces the pain of labor and makes it easier to manage. 4. The client will not need an episiotomy.

Answer: 1 Explanation: 1. Contractions after amniotomy are similar to those of spontaneous labor.

A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? 1. "A quick cool bath will help wake up my son for feedings." 2. "I can check my son's temperature under his arm." 3. "My baby should be dressed warmly, with a hat." 4. "Cuddling my son will help to keep him warm."

Answer: 1 Explanation: 1. Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal.

A 43-year-old client has just had a positive pregnancy test. She cries, and states, "I just don't know what I'll do. I can't be pregnant." Which nursing diagnosis would be the most appropriate? 1. Decisional Conflict related to unexpected pregnancy 2. Knowledge, Deficient related to advanced maternal age 3. Depression related to unexpected pregnancy 4. Health Maintenance, Ineffective related to advanced maternal age

Answer: 1 Explanation: 1. Decisional Conflict related to unexpected pregnancy is the most appropriate nursing diagnosis.

What would be a normal cervical dilatation rate in a first-time mother ("primip")? 1. 1.5 cm per hour 2. Less than 1 cm cervical dilatation per hour 3. 1 cm per hour 4. Less than 0.5 cm per hour

Answer: 1 Explanation: 1. Dilatation in a "multip" is about 1.5 cm per hour.

Doppler flow studies (umbilical velocimetry) help to assess which of the following? 1. Placental function and sufficiency 2. Fetal heart rate 3. Fetal growth and fluid levels 4. Maturity of the fetal lungs

Answer: 1 Explanation: 1. Doppler flow studies (umbilical velocimetry) help to assess placental function and sufficiency. Uteroplacental insufficiency is a risk for a woman with preeclampsia. If fetal growth restriction is present, Doppler velocimetry of the umbilical artery is useful for fetal surveillance.

The nurse is working with a client who has experienced a fetal death in utero at 20 weeks. The client asks what her baby will look like when it is delivered. Which statement by the nurse is best? 1. "Your baby will be covered in fine hair called lanugo." 2. "Your child will have arm and leg buds, not fully formed limbs." 3. "A white, cheesy substance called vernix caseosa will be on the skin." 4. "The genitals of the baby will be ambiguous."

Answer: 1 Explanation: 1. Downy fine hair called lanugo covers the body of a 20-week fetus.

A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity? 1. Patellar reflexes weak or absent 2. Increased appetite 3. Respiratory rate of 16 4. Fetal heart rate of 120

Answer: 1 Explanation: 1. Early signs of magnesium sulfate toxicity are related to a decrease in deep tendon reflexes.

A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate? 1. Encourage sitz baths. 2. Position the client in the supine position. 3. Avoid stool softeners. 4. Decrease fluid intake.

Answer: 1 Explanation: 1. Encouraging sitz baths is the correct approach because moist heat decreases inflammation and provides for comfort.

During a postpartum home visit, which step should the nurse take to establish a caring relationship? 1. Ask family members how they want to be addressed. 2. Do a portion of what the nurse agrees to do for the family, to avoid overwhelming them. 3. Speak directly to the father when asking questions. 4. Present information to the family instead of asking questions.

Answer: 1 Explanation: 1. Establishing a caring relationship starts with introducing yourself to the family and by calling the family members by their surnames until you have been invited to use the given or a less formal name.

A 38-year-old client in her second trimester states a desire to begin an exercise program to decrease her fatigue. What is the most appropriate nursing response? 1. "Fatigue should resolve in the second trimester, but walking daily might help." 2. "Avoid a strenuous exercise regimen at your age. Drink coffee to combat fatigue." 3. "Avoid an exercise regimen due to your pregnancy. Try to nap daily." 4. "Fatigue will increase as pregnancy progresses, but running daily might help."

Answer: 1 Explanation: 1. Even mild to moderate exercise is beneficial during pregnancy. Regular exercise-at least 30 minutes of moderate exercise daily or at least most days of the week-is preferred.

An analgesic medication has been administered intramuscularly to a client in labor. How would the nurse evaluate if the medication was effective? 1. The client dozes between contractions. 2. The client is moaning during contractions. 3. The contractions decrease in intensity. 4. The contractions decrease in frequency.

Answer: 1 Explanation: 1. If the client dozes between contractions, the analgesic is effective. Analgesics decrease discomfort and increase relaxation.

The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? 1. "In the first 3 to 4 months breastfed babies tend to gain weight faster." 2. "In the first 3 to 4 months there is no difference in weight gain." 3. "In the first 3 to 4 months bottle-fed babies grow faster." 4. "In the first 3 to 4 months growth isn't as important as your comfort with the method."

Answer: 1 Explanation: 1. Exclusively breastfed infants have the same or slightly higher weight gain than their formula-fed and combination-fed peers in the first 3 to 4 months.

The nurse obtains a health history from four clients. To which client should she give priority for teaching about cervical cancer prevention? 1. Age 30, treated for PID 2. Age 25, monogamous 3. Age 20, pregnant 4. Age 27, uses a diaphragm

Answer: 1 Explanation: 1. Exposure to sexually transmitted infections increases the risk of abnormal cell changes and cervical cancer.

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for which of the following? 1. Visual impairment 2. Hyperthermia 3. Central cyanosis 4. Sensitive gag reflex

Answer: 1 Explanation: 1. Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina causing characteristic retinal changes known as retinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has become the norm.

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection

Answer: 1 Explanation: 1. Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding.

The nurse is teaching a woman about her menstrual cycle. Which is the most important change that happens during the follicular phase of the menstrual cycle? 1. Maturation of the primordial follicle 2. Multiplication of the fimbriae 3. Secretion of human chorionic gonadotropin 4. Growth of the endometrium

Answer: 1 Explanation: 1. Follicle-stimulating hormone is elevated during the follicular phase, and the primordial follicle matures.

A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? 1. Spinal 2. Pudendal 3. General 4. Epidural

Answer: 1 Explanation: 1. Following the birth, the woman may be kept flat. Although the effectiveness of the supine position to avoid headache following a spinal is controversial, the physician's orders may include lying flat for 6 to 12 hours.

The nurse is caring for a laboring client with thrombocytopenia. During labor, it is determined that the client requires a cesarean delivery. The nurse is preparing the client for surgery, and should instruct the client that the recommended method of anesthesia is which of the following? 1. General anesthesia 2. Epidural anesthesia 3. Spinal anesthesia 4. Regional anesthesia

Answer: 1 Explanation: 1. General anesthesia will be recommended. Women with thrombocytopenia should avoid regional blocks.

The nurse obtains a health history from four clients. To which client should she give priority for teaching about cervical cancer prevention? 1. Age 37, multiple partners 2. Age 22, abstains from sexual intercourse 3. Age 32, pregnant with twins 4. Age 27, uses female condom

Answer: 1 Explanation: 1. Having multiple partners increases the client's risk of contracting sexually transmitted infections, including possible exposure to human papilloma virus (HPV). Contracting HPV increases risk of abnormal cervical cell changes and cervical cancer.

The nurse is teaching nursing students about the different kind of hepatitis. Which statement is the nurse likely to make? 1. Hepatitis A and B have vaccines to prevent them. 2. Hepatitis A, B, and C have vaccines to prevent them. 3. Hepatitis C, D, and E are all bloodborne. 4. Hepatitis A, C, and E are all fecal-oral contamination.

Answer: 1 Explanation: 1. Hepatitis A and B are the only two types of hepatitis that have vaccines.

The nurse is caring for a pregnant woman who admits to using cocaine and ecstasy on a regular basis. The client states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal about ecstasy?" What is the nurse's best response? 1. "Ecstasy can cause a high fever in you and therefore cause the baby harm." 2. "Ecstasy leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "Ecstasy produces babies with small heads and short bodies with brain function alterations." 4. "Ecstasy produces intrauterine growth restriction and meconium aspiration."

Answer: 1 Explanation: 1. Hyperthermia (elevated temperature) is a side effect of MDMA (ecstasy).

The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia.

Answer: 1 Explanation: 1. IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum).

A woman's history and appearance suggest drug abuse. What is the nurse's best approach? 1. Ask the woman directly, "Do you use any street drugs?" 2. Ask the woman whether she would like to talk to a counselor. 3. Ask some questions about over-the-counter medications and avoid mention of illicit drugs. 4. Explain how harmful drugs can be for her baby.

Answer: 1 Explanation: 1. If drug abuse is suspected, the nurse should ask direct questions and be matter-of-fact and nonjudgmental to elicit honest responses.

The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."

Answer: 1 Explanation: 1. If the mother finds that one area of her breast feels distended or lumpy, she can massage the lumpy area toward the nipple as the infant nurses.

A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? 1. A soaked perineal pad since the last 15-minute check 2. An edematous perineum 3. The client experiencing tremors 4. A fundus located at the umbilicus

Answer: 1 Explanation: 1. If the perineal pad becomes soaked in a 15-minute period or if blood pools under the buttocks, continuous observation is necessary. As long as the woman remains in bed during the first hour, bleeding should not exceed saturation of one pad.

A nurse is caring for a client admitted preoperatively for a bilateral mastectomy. Which statement indicates that this client is still in the shock phase of adjustment to her diagnosis? 1. "I can't understand why this is happening to me." 2. "I am so happy that my daughter graduates from high school this year." 3. "I know that breast cancer is now part of my life." 4. "I can't believe that I need to lose both of my breasts."

Answer: 1 Explanation: 1. In the shock phase, a client makes statements such as this.

The client gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. What should the nurse prepare to do? 1. Start an IV of lactated Ringer's. 2. Apply anti-embolism stockings. 3. Bottle-feed the infant. 4. Send the placenta to pathology.

Answer: 1 Explanation: 1. In women who do not have an epidural in place, intravenous sedation may be required because of the discomfort caused by the procedure. An IV is necessary.

A 28-year-old woman has been an insulin-dependent diabetic for 10 years. At 36 weeks' gestation, she has an amniocentesis. A lecithin/sphingomyelin (L/S) ratio test is performed on the sample of her amniotic fluid. Because she is a diabetic, what would an obtained 2:1 ratio indicate for the fetus? 1. The fetus may or may not have immature lungs. 2. The amniotic fluid is contaminated. 3. The fetus has a neural tube defect. 4. There is blood in the amniotic fluid.

Answer: 1 Explanation: 1. Infants of diabetic mothers (IDMs) have a high incidence of false-positive results (i.e., the L/S ratio is thought to indicate lung maturity, but after birth the baby develops RDS).

Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of which condition? 1. Intrauterine growth restriction 2. Oliguria 3. Proteinuria 4. Hypertension

Answer: 1 Explanation: 1. Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of intrauterine growth restriction. The cause is related specifically to maternal vasospasm and hypovolemia, which result in fetal hypoxia and malnutrition.

The client with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client? 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. Vascular disease that accompanies diabetes slows progression. 4. The baby is likely to have a congenital abnormality because of the diabetes.

Answer: 1 Explanation: 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase.

The homecare nurse is visiting a newborn-and-mother couplet. Which nursing action has the highest priority? 1. Establish rapport with the family members. 2. Review the hospital medical records. 3. Determine the newborn's sleeping arrangements. 4. Examine the umbilical cord stump.

Answer: 1 Explanation: 1. It is critical to establish rapport with family members prior to beginning any assessments. The nurse can rely on the same characteristics of a caring relationship that have been integral to hospital-based practice-regard for patients, genuineness, empathy, and establishment of trust and rapport. Page Ref: 916

The nurse is planning to teach couples factors that influence fertility. Which factor should not be included in the teaching plan? 1. Sexual intercourse should occur every day of the week. 2. Get up to urinate 1 hour after intercourse. 3. Do not douche. 4. Institute stress-reduction techniques.

Answer: 1 Explanation: 1. It is optimal if sexual intercourse occurs every other day during the fertile period.

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? 1. Jitteriness 2. Sucking on fingers 3. Lusty cry 4. Axillary temperature of 98°F

Answer: 1 Explanation: 1. Jitteriness of the newborn is associated with hypoglycemia. Aggressive treatment is recommended after a single low blood glucose value if the infant shows this symptom.

The nurse is responding to phone calls. Whose call should the nurse return first? 1. A client at 37 weeks' gestation reports no fetal movement for 24 hours. 2. A client at 29 weeks' gestation reports increased fetal movement. 3. A client at 32 weeks' gestation reports decreased fetal movement X 2 days. 4. A client at 35 weeks' gestation reports decreased fetal movement X 4 hours.

Answer: 1 Explanation: 1. Lack of fetal movement can be an indication of nonreassuring fetal status or even fetal death. This client is the highest priority.

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature 2. An increase of serum bilirubin levels 3. Weight loss 4. Skin blanching yellow

Answer: 1 Explanation: 1. Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy. The isolette helps the infant maintain his or her temperature while undressed.

A client comes to the clinic complaining of difficulty urinating, flu-like symptoms, genital tingling, and blister-like vesicles on the upper thigh and vagina. She denies having ever had these symptoms before. The medication the physician is most likely to order would be: 1. Oral acyclovir 2. Ceftriaxone IM 3. Azithromycin p.o. 4. Penicillin G IM

Answer: 1 Explanation: 1. Malaise, dysuria, and tingling or painful vesicles are indicative of a primary herpes simplex outbreak. Acyclovir treats herpes.

The nurse working on a postoperative gynecology unit has to be knowledgeable of the psychological concerns of many of her clients. What will these concerns most often include? 1. Feelings of loss, grief, and anger 2. Feelings of euphoria and happiness 3. Feelings of control and calmness 4. Feelings of cheerfulness and satisfaction

Answer: 1 Explanation: 1. Many gynecological procedures have the potential to involve loss, so grieving, anger, sadness, and loss of control are just a few of the feelings the woman might experience.

The primiparous client has told the nurse that she is afraid she will develop hemorrhoids during pregnancy because her mother did. Which statement would be best for the nurse to make? 1. "It is not unusual for women to develop hemorrhoids during pregnancy." 2. "Most women don't have any problem until after they've delivered." 3. "If your mother had hemorrhoids, you will get them, too." 4. "If you get hemorrhoids, you probably will need surgery to get rid of them."

Answer: 1 Explanation: 1. Many pregnant women will develop hemorrhoids. Hemorrhoids are varicosities of the veins in the lower end of the rectum and anus. During pregnancy, the gravid uterus presses on the veins and interferes with venous circulation. As the pregnancy progresses, the straining that accompanies constipation can contribute to the development of hemorrhoids.

The client at 20 weeks' gestation thinks she might have been exposed to a toxin at work that could affect fetal development. The client asks the nurse what organs might be affected at this point in pregnancy. What is the nurse's best response? 1. "The brain is developing now, and could be affected." 2. "Because you are in the second trimester, there is no danger." 3. "The internal organs like the heart and lungs could be impacted." 4. "It's best to not worry about possible problems with your baby."

Answer: 1 Explanation: 1. Maximum brain growth and myelination are occurring at this point in fetal development.

The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? 1. Methylergonovine maleate (Methergine) 2. Rh immune globulin (RhoGAM) 3. Terbutaline (Brethine) 4. Docusate (Colace)

Answer: 1 Explanation: 1. Methylergonovine maleate is the drug used for the prevention and control of postpartum hemorrhage.

A new mother at 36 hours post-delivery has asked to be discharged to home. The nurse explains that criteria for discharge before the newborn is 48 hours old include which of the following? 1. The newborn's respiratory rate is less than 60/min. 2. Singleton birth at a minimum 35 weeks' gestation. 3. The newborn has passed at least three spontaneous stools. 4. The newborn has normal and stable vital signs for 24 hours before discharge.

Answer: 1 Explanation: 1. Minimal criteria include a respiratory rate in the newborn less than 60/min.

The nurse in a fertility clinic is working with a woman who has been undergoing infertility treatment with clomiphene citrate. Which statement would the nurse expect the woman to make? 1. "I feel moody so much of the time." 2. "If this doesn't work, I think my husband will leave me." 3. "This medication will guarantee a pregnancy." 4. "My risk of twins or triplets is the same as for the general population."

Answer: 1 Explanation: 1. Mood swings are a side effect of clomiphene citrate.

The nurse teaching the expectant parents about the placenta also talks about the circulation and how the fetus gets its oxygen. She will include in this teaching which important fact? 1. The placenta functions as the lungs for the fetus. 2. The fetus obtains its oxygen from the amniotic fluid. 3. The fetus receives its oxygen by osmosis from the mother's bloodstream. 4. Fetal circulation delivers the highest amount of oxygen to the abdomen and lower body of the fetus.

Answer: 1 Explanation: 1. Most of the blood supply bypasses the fetal lungs because they do not carry out respiratory gas exchange. The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the fetus to excrete carbon dioxide into the maternal bloodstream.

A woman in active labor is given nalbuphine hydrochloride (Nubain) 14 mg IV for pain relief. Half an hour later, her respirations are at 8 per minute. The physician would likely order which medication for this client? 1. Narcan 2. Reglan 3. Benadryl 4. Vistaril

Answer: 1 Explanation: 1. Narcan is useful for respiratory depression caused by nalbuphine (Nubain).

A Navajo client who is 36 weeks pregnant meets with a traditional healer as well as her physician. What does the nurse understand this to mean? 1. The client is seeking spiritual direction. 2. The client does not trust her physician. 3. The client will not adapt to mothering well. 4. The client is experiencing complications of pregnancy.

Answer: 1 Explanation: 1. Navajo clients are aware of the mind-soul connection, and might try to follow certain practices to have a healthy pregnancy and birth. Practices could include focus on peace and positive thoughts as well as certain types of prayers and ceremonies. A traditional healer may assist them.

The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? 1. Offer early feedings. 2. Administer an intravenous infusion of glucose. 3. Assess for hypercalcemia. 4. Assess for hyperbilirubinemia immediately after birth.

Answer: 1 Explanation: 1. Newborns of diabetic mothers may benefit from early feeding as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia.

The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? 1. "Newborns should regain their birth weight by 1 week of age." 2. "Breastfed and formula-fed babies have different growth rates." 3. "Formula-fed infants regain their birth weight earlier than breastfed infant." 4. "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition."

Answer: 1 Explanation: 1. Newborns should gain at least 10 g/kg/day and be back to birth weight no later than day 14 of life.

In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia.

Answer: 1 Explanation: 1. Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings.

The nurse is assessing a new mother 2 days after a normal vaginal delivery. The mother has chosen not to breastfeed. What would an abnormal finding be? 1. Weight loss of 3 pounds 2. Small amount of breast milk expressed 3. Pink striae on the abdomen 4. Lochia serosa

Answer: 1 Explanation: 1. Normal weight loss postpartum is in the range of 12 to 20-plus pounds.

The nurse is caring for a client pregnant with twins. Which statement indicates that the client needs additional information? 1. "Because both of my twins are boys, I know that they are identical." 2. "If my twins came from one fertilized egg that split, they are identical." 3. "If I have one boy and one girl, I will know they came from two eggs." 4. "It is rare for both twins to be within the same amniotic sac."

Answer: 1 Explanation: 1. Not all same-sex twins are identical or monozygotic, because fraternal, or dizygotic, twins can be the same gender or different genders.

The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? 1. "Most newborns are nose breathers." 2. "The tube will elicit the sucking reflex." 3. "A smaller catheter is preferred for feedings." 4. "Most newborns are mouth breathers."

Answer: 1 Explanation: 1. Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers.

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done? 1. To contract the uterus and minimize bleeding 2. To decrease breast milk production 3. To decrease maternal blood pressure 4. To increase maternal blood pressure

Answer: 1 Explanation: 1. Oxytocin is given to contract the uterus and minimize bleeding.

A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for? 1. Oxytocin induction of labor 2. Amnioinfusion 3. Increased intravenous infusion 4. Cesarean section

Answer: 1 Explanation: 1. Oxytocin is the drug of choice for labor augmentation or labor induction and may be administered as needed for hypotonic labor patterns.

What information should the nurse include when teaching a new mother how to successfully bottle-feed her newborn? 1. Proper dilution of powdered formula is essential to provide adequate nutrition. 2. Keep formula at room temperature for at least 4 hours to warm it, instead of microwaving it. 3. Use enough water to dilute the nutrient and calorie density so the infant will drink more formula. 4. Freeze newly prepared formula for up to 3 months.

Answer: 1 Explanation: 1. Parents should be instructed to follow the directions on the formula can label precisely as written.

A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? 1. "Take your newborn to the pediatrician." 2. "Cover the cord stump with gauze." 3. "Apply Betadine around the cord stump." 4. "This is normal during healing."

Answer: 1 Explanation: 1. Parents should check cord each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to healthcare provider any signs of infection.

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? 1. "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." 2. "The infant received too many red blood cells after delivery because the cord was not clamped immediately." 3. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 4. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should."

Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence, and peaks at 3 to 5 days in term infants. The reduction in hepatic activity, along with a relatively large bilirubin load, decreases the liver's ability to conjugate bilirubin and increases susceptibility to jaundice.

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? 1. Physiologic jaundice is normal, and peaks at this age. 2. The newborn's liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring.

Answer: 1 Explanation: 1. Physiologic jaundice occurs soon after birth. Bilirubin levels peak at 3 to 5 days in term infants.

The nurse knows that a contraindication to the induction of labor is which of the following? 1. Placenta previa 2. Isoimmunization 3. Diabetes mellitus 4. Premature rupture of membranes

Answer: 1 Explanation: 1. Placenta previa is a contraindication to the induction of labor.

A breastfeeding postpartum client reports sore nipples to the nurse during a home visit. What intervention would be the highest priority? 1. Infant positioning 2. Use of the breast shield 3. Use of breast pads 4. Type of soap used

Answer: 1 Explanation: 1. Poor latch and/or suck are the primary causes of nipple soreness and the baby's position at the breast is a critical factor in nipple soreness. Encouraging the mother to rotate positions when feeding the infant may decrease nipple soreness. Changing positions alters the focus of greatest stress and promotes more complete breast emptying.

The nurse is inducing the labor of a client with severe preeclampsia. As labor progresses, fetal intolerance of labor develops. The induction medication is turned off, and the client is prepared for cesarean birth. Which statement should the nurse include in her preoperative teaching? 1. "Because of your preeclampsia you are at higher risk for hypotension after an epidural anesthesia." 2. "Because of your preeclampsia you might develop hypertension after a spinal anesthesia." 3. "Because of your preeclampsia your baby might have decreased blood pressure after birth." 4. "Because of your preeclampsia

Answer: 1 Explanation: 1. Pregnancies complicated by preeclampsia are high-risk situations. The woman with mild preeclampsia usually may have the analgesia or anesthesia of choice, although the incidence of hypotension with epidural anesthesia is increased. If hypotension occurs with the epidural block, it provides further stress on an already compromised cardiovascular system.

The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? 1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding, and will wet often." 3. "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." 4. "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."

Answer: 1 Explanation: 1. Putting a baby to bed with a propped bottle is a choking hazard, and should never be done.

The nurse is reviewing charts of clients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased health care costs in clients undergoing cesarean birth by request? 1. Increased abnormal placenta implantation in subsequent pregnancies 2. Decreased use of general anesthesia with greater use of epidural anesthesia 3. Prolonged anemia, requiring blood transfusions every few months 4. Coordination of career projects of both partners leading to increased income

Answer: 1 Explanation: 1. Repeat cesarean births are associated with greater risks including increased incidence of abnormal placentation in subsequent pregnancies and the increased risk of mortality secondary to surgery, which would contribute to increased health care costs.

The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following? 1. Help the new mother by allowing her to focus on resting and caring for the baby. 2. Teach her son-in-law the right way to be a father because this is his first child. 3. Make sure that her daughter does not become abusive towards the infant. 4. Pass on the cultural values and beliefs to the newborn grandchild.

Answer: 1 Explanation: 1. Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods.

The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective? 1. "I need to get RhoGAM so I don't have problems with my next pregnancy." 2. "Because my baby is Rh-positive, I don't need RhoGAM." 3. "If my baby had the same blood type I do, it might cause complications." 4. "Before my next pregnancy, I will need to have a RhoGAM shot."

Answer: 1 Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization.

A pregnant client asks the nurse, "What is this "knuckle test" that is supposed to tell whether my baby has a genetic problem?" What does the nurse correctly explain? 1. "In the first trimester, the nuchal translucency measurement is added to improve the detection rate for Down syndrome and trisomy 18." 2. "You will need to ask the physician for an explanation." 3. "It tests for hemophilia A or B." 4. "It tests for Duchenne muscular dystrophy."

Answer: 1 Explanation: 1. Screening tests, such as nuchal translucency ultrasound are designed to gather information about the risk that the pregnancy could have chromosome abnormalities or open spina bifida.

Which of the following conditions would predispose a client for thrombophlebitis? 1. Severe anemia 2. Cesarean delivery 3. Anorexia 4. Hypocoagulability

Answer: 1 Explanation: 1. Severe anemia would predispose a client for thrombophlebitis.

The introduction of a new baby into the family is often the beginning of which of the following? 1. Sibling rivalry 2. Inconsistent childrearing 3. Toilet training 4. Weaning

Answer: 1 Explanation: 1. Sibling rivalry results from children's fear of change in the security of their relationships with their parents.

The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "A baby's kidneys don't concentrate urine well for several months." 3. "Feeding our baby frequently will help the kidneys function." 4. "Kidney function in an infant is very different from that in an adult."

Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue.

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? 1. "Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 2. "My first baby was in a breech position, so for this pregnancy, I can try a VBAC if the baby is head-down." 3. "Because my hospital is so small and in a rural area, they won't let me attempt a VBAC." 4. "The rate of complications from VBAC is lower than the rate of complications from a cesarean."

Answer: 1 Explanation: 1. Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding whether VBAC is advisable. The classic vertical incision was commonly done in the past and is associated with increased risk of uterine rupture in subsequent pregnancies and labor.

The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? 1. Large amounts of uric acid crystals in the first days of life 2. At least 6 to 10 wet diapers a day after the first few days of life 3. 1 to 2 stools a day for formula-fed baby 4. Urine that is straw to amber color without foul smell

Answer: 1 Explanation: 1. Small, not large, amounts of uric acid crystals are normal in the first days of life.

After teaching a pregnant client about the effects of smoking on pregnancy, the nurse knows that the client needs further education when she makes which statement? 1. "I am at increased risk for preeclampsia." 2. "I am at increased risk for preterm birth." 3. "I am at increased risk for placenta previa." 4. "I am at increased risk for abruptio placentae."

Answer: 1 Explanation: 1. Smoking is not associated with increased risk for preeclampsia.

A client tells you that her mother was a twin, two of her sisters have twins, and several cousins either are twins or gave birth to twins. The client, too, is expecting twins. Because there is a genetic predisposition to twins in her family, there is a good chance that the client will have what type of twins? 1. Dizygotic twins 2. Monozygotic twins 3. Identical twins 4. Nonzygotic twins

Answer: 1 Explanation: 1. Studies indicate that dizygotic twins tend to occur in certain families, perhaps because of genetic factors that result in elevated serum gonadotropin levels leading to double ovulation.

The nurse seeing a client just diagnosed with Chlamydia trachomatis knows that which client is at greatest risk for the infection? 1. 16-year-old sexually active girl, using no contraceptive 2. 22-year-old mother of two, developed dyspareunia 3. 35-year-old woman on oral contraceptives 4. 48-year-old woman with hot flashes and night sweats

Answer: 1 Explanation: 1. Teens have the highest incidence of sexually transmitted infections, especially chlamydia. A client not using contraceptives is not using condoms, which decrease the risk of contracting a STI.

The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? 1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." 2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." 3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." 4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."

Answer: 1 Explanation: 1. Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. The severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect.

A client describes breast swelling and tenderness. What piece of data would be most important for the nurse to gather initially? 1. Timing of the symptoms 2. Birth control method 3. Method of breast self-examination 4. Diet history

Answer: 1 Explanation: 1. The breast undergoes regular cyclical changes in response to hormonal stimulation. The nurse will want to determine when the swelling and tenderness occur within the menstrual cycle.

Two hours ago, a client at 39 weeks' gestation was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every 5 minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40-50 seconds' duration and intensity of 40 mmHg. What would the priority intervention be? 1. Begin oxytocin after assessing for CPD. 2. Give terbutaline to stop the preterm labor. 3. Start oxygen at 8 L/min. 4. Have the anesthesiologist give the client an epidural.

Answer: 1 Explanation: 1. The client is having hypertonic contractions. Cephalopelvic disproportion (CPD) must be excluded. If CPD exists, oxytocin (Pitocin) augmentation should not be used. Oxytocin is the drug of choice for labor augmentation or labor induction.

The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? 1. "If your incision becomes increasingly painful, call the doctor." 2. "It is normal for the incision to ooze greenish discharge in a few days." 3. "Increasing redness around the incision is a part of the healing process." 4. "A fever is to be expected because you had a surgical delivery."

Answer: 1 Explanation: 1. The client should call the doctor if the incision becomes increasingly painful. After cesarean delivery, wound infection is most often associated with concurrent endometritis. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. Some women have cellulitis without actual purulent drainage.

The nurse is working with a woman who is undergoing chemotherapy for breast cancer. The client states, "First, the cancer seemed unreal. Now I feel like I can cope." What is the nurse's best response? 1. "Women with breast cancer often go through several stages of adjustment." 2. "Women with breast cancer cope better than their partners cope." 3. "Women with breast cancer seek multiple opinions before starting treatment." 4. "Women with breast cancer become angry after treatment begins."

Answer: 1 Explanation: 1. The course of adjustment confronting the woman with cancer has been described in four phases: shock, reaction, recovery, and reorientation. The client's statement indicates shock followed by reaction.

To identify the duration of a contraction, the nurse would do which of the following? 1. Start timing from the beginning of one contraction to the completion of the same contraction. 2. Time between the beginning of one contraction and the beginning of the next contraction. 3. Palpate for the strength of the contraction at its peak. 4. Time from the beginning of the contraction to the peak of the same contraction.

Answer: 1 Explanation: 1. The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction.

The pregnant client who is at 14 weeks' gestation asks the nurse why the doctor used to call her baby an embryo, and now calls it a fetus. What is the best answer to this question? 1. "A fetus is the term used from the ninth week of gestation and onward." 2. "We call a baby a fetus when it is larger than an embryo." 3. "An embryo is a baby from conception until the eighth week." 4. "The official term for a baby in utero is really zygote."

Answer: 1 Explanation: 1. The fetal stage begins in the ninth week.

The prenatal clinic nurse has received four phone calls. Which client should the nurse call back first? 1. Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing and shortness of breath 2. Pregnant woman at 6 weeks with a seizure disorder who is inquiring which foods are good folic acid sources for her 3. Pregnant woman at 35 weeks with a positive HBsAG who is wondering what treatment her baby will receive after birth 4. Pregnant woman at 11 weeks with untreated hyperthyroidism who is describing the onset of vaginal bleeding

Answer: 1 Explanation: 1. The goal of therapy is to prevent maternal exacerbations because even a mild exacerbation can cause severe hypoxia-related complications in the fetus.

The nurse is presenting a class to women who are currently pregnant or are planning pregnancy in the near future. Which client statement indicates that additional teaching is required? 1. "The older a woman is when she conceives, the safer the pregnancy is." 2. "Pregnant teens can have additional nutritional needs." 3. "A woman whose sisters all had hypertension will be watched carefully." 4. "Pregnancy may be more difficult to achieve in my 40s."

Answer: 1 Explanation: 1. The health risks associated with pregnancy vary by age. The risk for maternal death is significantly higher for women over age 35 and even higher for women age 40 and older. The incidence of low-birth-weight infants, preterm births, miscarriage, stillbirth, and perinatal morbidity and mortality is higher among women age 35 or older.

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? 1. "Newborns have immature immune function at birth, and illness is very hard to detect." 2. "Your mothering skills will improve with time. You should take the newborn class." 3. "Your baby didn't get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old."

Answer: 1 Explanation: 1. The immune responses in neonates are usually functionally impaired when compared with adults.

What is the major adverse side effect of epidural anesthesia? 1. Maternal hypotension 2. Decrease in variability of the FHR 3. Vertigo 4. Decreased or absent respiratory movements

Answer: 1 Explanation: 1. The major adverse effect of epidural anesthesia is maternal hypotension caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers blood pressure.

After administration of an epidural anesthetic to a client in active labor, it is most important to assess the mother immediately for which of the following? 1. Hypotension 2. Headache 3. Urinary retention 4. Bradycardia

Answer: 1 Explanation: 1. The most common complication of an epidural is maternal hypotension.

The OB-GYN nurse knows that the most common shape for the female pelvis is which of the following? 1. Gynecoid type 2. Android type 3. Anthropoid type 4. Platypelloid type

Answer: 1 Explanation: 1. The most common female pelvis is the gynecoid type. The inlet is rounded with the anteroposterior diameter a little shorter than the transverse diameter.

What is one of the most common initial signs of nonreassuring fetal status? 1. Meconium-stained amniotic fluid 2. Cyanosis 3. Dehydration 4. Arrest of descent

Answer: 1 Explanation: 1. The most common initial signs of nonreassuring fetal status are meconium-stained amniotic fluid and changes in the fetal heart rate (FHR).

Which of the following behaviors noted in the postpartum client would require the nurse to assess further? 1. Responds hesitantly to infant cries. 2. Expresses satisfaction about the sex of the baby. 3. Friends and family visit the client and give advice. 4. Talks to and cuddles with the infant frequently.

Answer: 1 Explanation: 1. The mother tends to respond verbally to any sounds emitted by the newborn, such as cries, coughs, sneezes, and grunts. Responding hesitantly to infant cries might need further assessment to determine what the mother is feeling.

The nurse is conducting several home visits over the course of a week. Which action is appropriate to maintain safety? 1. Provide a daily schedule of visits to supervisors, including client addresses and phone numbers. 2. Maintain distance from threatening pets but do not insist that they be kept out of the room. 3. If an unsafe situation arises, discuss safety concerns with the client before continuing with the visit. 4. Lock personal belongings in the car trunk prior to entering the client's home.

Answer: 1 Explanation: 1. The nurse should notify the supervisor when leaving for a visit, and should check in as soon as the visit is completed.

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? 1. Initial resuscitation 2. Vigorous stimulation at birth 3. Phototherapy immediately 4. An initial feeding of iron-enriched formula

Answer: 1 Explanation: 1. The presence of meconium in the amniotic fluid indicates that the fetus may be suffering from asphyxia. Meconium-stained newborns or newborns who have aspirated particulate meconium often have respiratory depression at birth and require resuscitation to establish adequate respiratory effort.

It is 1 week before a pregnant client's due date. The nurse notes on the chart that the client's pulse rate was 74-80 before pregnancy. Today, the client's pulse rate at rest is 90. What action should the nurse should take? 1. Chart the findings. 2. Notify the physician of tachycardia. 3. Prepare the client for an electrocardiogram (EKG). 4. Prepare the client for transport to the hospital.

Answer: 1 Explanation: 1. The pulse rate frequently increases during pregnancy, although the amount varies from almost no increase to an increase of 10 to 15 beats per minute. This is a normal response, and does not indicate a need for emergency measures or treatment.

At 32 weeks' gestation, a woman is scheduled for a second non-stress test (following one she had at 28 weeks' gestation). Which statement by the client would indicate an adequate understanding of this procedure? 1. "I can't get up and walk around during the test." 2. "I'll have an IV started before the test." 3. "I can still smoke before the test." 4. "I need to have a full bladder for this test."

Answer: 1 Explanation: 1. The purpose of the non-stress test is to determine the results of movement on fetal heart rate. The NST is typically performed with the woman in the semi-Fowler's position with a small pillow or blanket under the right hip to displace the uterus to the left.

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? 1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. 2. Use a previous puncture site. 3. Cool the heel prior to obtaining blood. 4. Use a sterile needle and aspirate.

Answer: 1 Explanation: 1. The site should be cleaned by rubbing vigorously with 70% isopropyl alcohol swab. The friction produces local heat, which aids vasodilation.

The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? 1. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." 2. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 3. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 4. "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."

Answer: 1 Explanation: 1. The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome.

After being in labor for several hours with no progress, a client is diagnosed with CPD (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? 1. Transverse 2. Infraumbilical midline 3. Classic 4. Vertical

Answer: 1 Explanation: 1. The transverse incision is made across the lowest and narrowest part of the abdomen and is the most common lower uterine segment incision.

The nurse teaching a class on reproductive anatomy knows that no further instruction is needed when a student shows an understanding of the pelvic cavity divisions by making which statement? 1. "The true pelvis is made up of the sacrum, coccyx, and innominate bones." 2. "The false pelvis consists of the inlet, the pelvic cavity, and the outlet." 3. "The true pelvis is the portion above the pelvic brim." 4. "The relationship between the false pelvis and the fetal head is of paramount importance."

Answer: 1 Explanation: 1. The true pelvis is made up of the sacrum, the coccyx, and the two innominate bones.

The clinic nurse teaches the pregnant client being treated for trichomoniasis about the risks to her pregnancy due to this infection. Which statement would indicate successful teaching? 1. "I am at risk of having a preterm birth because of this infection." 2. "I might need to have my membranes ruptured because of this infection." 3. "I am at risk of having a baby with a high birth weight." 4. "I may have intercourse with my husband while bring treated for this infection."

Answer: 1 Explanation: 1. There is a risk of preterm birth and rupture of membranes.

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes.

Answer: 1 Explanation: 1. This action is correct. Specific gravity provides one measure of urine concentration. Highly concentrated urine is associated with a dehydrated state. Weight loss is also a sign of developing dehydration in the newborn.

The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory 2. 23-year-old of low socioeconomic status, unmarried 3. 16-year-old who began prenatal care at 30 weeks 4. 28-year-old with a history of gestational diabetes

Answer: 1 Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.

The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? 1. Assist the client to the bathroom in 2 hours to void. 2. Place a Foley catheter now. 3. Apply warm packs to the perineum three times a day. 4. Allow the client to rest for the next 8 hours.

Answer: 1 Explanation: 1. This client is at risk for urinary retention and bladder overdistention. Overdistention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention.

The nurse asks a woman how her husband is dealing with the pregnancy. The nurse concludes that counseling is needed when the woman makes which statement? 1. "My husband is ready for the pregnancy to end so that we can have sex again." 2. "My husband is much more attentive to me now that I am pregnant." 3. "My husband seems more worried about our finances now than he was before the pregnancy." 4. "My husband plays his favorite music for my belly so the baby will learn to like it."

Answer: 1 Explanation: 1. This is implying that the woman and her husband are not having sex, which indicates the need for counseling. Sex is fine with a normal pregnancy.

Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? 1. Massage the fundus until firm 2. Express retained clots 3. Increase the intravenous solution 4. Call the physician

Answer: 1 Explanation: 1. When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm.

The nurse educator is presenting a program to college students about factors that can cause congenital malformations. What should the nurse tell them? 1. The growing embryo is considered most vulnerable to hazardous agents during the first months of pregnancy. 2. Spontaneous abortion always occurs if the fetus is affected by a teratogen. 3. Potential teratogens can cause malformations of the heart, limbs, eyes, and other organ systems only in the second trimester. 4. Teratogen agents are primarily drugs.

Answer: 1 Explanation: 1. This is true. Because organs are formed primarily during embryonic development, the growing embryo is considered most vulnerable to hazardous agents during the first months of pregnancy.

After explaining how meiotic division occurs within the ovum, the nurse knows that the pregnant client understands when she makes what statement? 1. "The second meiotic division is arrested until and unless the oocyte is fertilized." 2. "Meiosis in the oocyte begins at puberty." 3. "The first meiotic division continues when the female infant is born." 4. "Fertilization does not take place in the secondary oocyte."

Answer: 1 Explanation: 1. This is true. The secondary oocyte moves into the metaphase stage of cell division, where its meiotic division is arrested until and unless the oocyte is fertilized.

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? 1. This weight loss is excessive. 2. This weight loss is within normal limits. 3. This weight gain is excessive. 4. This weight gain is within normal limits.

Answer: 1 Explanation: 1. This newborn has lost more than 10% of the birth weight; this weight loss is excessive. Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns.

The client at 14 weeks' gestation has undergone a transvaginal ultrasound to assess cervical length. The ultrasound revealed cervical funneling. How should the nurse explain these findings to the client? 1. "Your cervix has become cone-shaped and more open at the end near the baby." 2. "Your cervix is lengthened, and you will deliver your baby prematurely." 3. "Your cervix is short, and has become wider at the end that extends into the vagina." 4. "Your cervix was beginning to open but now is starting to close up again."

Answer: 1 Explanation: 1. Transvaginal ultrasound can most accurately identify shortened cervical length and cervical funneling, which is a cone-shaped indentation in the cervical os indicating cervical insufficiency or risk of preterm labor.

The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? 1. Obtain a blood calcium level. 2. Take the newborn's temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn.

Answer: 1 Explanation: 1. Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant.

By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? 1. Recognizing the client as an active participant in her own care. 2. Attempting to correct any misinformation the client might have received. 3. Acting as an advocate for the client. 4. Establishing rapport with the client.

Answer: 1 Explanation: 1. Understanding the couple's expectations and plans helps the nurse provide optimal nursing care and facilitate the best possible birth experience.

The client has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond? 1. "Sometimes the uterus relaxes and excessive bleeding occurs." 2. "The blood collected in the vagina and poured out when your partner stood up." 3. "Bottle-feeding prevents the uterus from getting enough stimulation to contract." 4. "The placenta had embedded in the uterine tissue abnormally."

Answer: 1 Explanation: 1. Uterine atony (relaxation of the uterus) is the leading cause of early postpartum hemorrhage, accounting for over 50% of postpartum hemorrhage cases.

The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed to perform which procedure? 1. A version 2. An amniotomy 3. Leopold maneuvers 4. A ballottement

Answer: 1 Explanation: 1. Version, or turning the fetus, is a procedure used to change the fetal presentation by abdominal or intrauterine manipulation.

) A client is concerned because she has been told her blood type and her baby's are incompatible. What is the nurse's best response? 1. "This is called ABO incompatibility. It is somewhat common but rarely causes significant hemolysis." 2. "This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy." 3. "This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby." 4. "This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring."

Answer: 1 Explanation: 1. When blood types, not Rh, are incompatible, it is called ABO incompatibility. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal RBCs.

The nurse is making an initial visit to a postpartum family's home. The mother states that she is having difficulty with breastfeeding. Which resource should the nurse tell the family about? 1. The lactation consultant at the hospital 2. Free immunizations through the county public health department clinics 3. Sources of free formula at a local food pantry 4. A support group for mothers who are experiencing postpartum depression

Answer: 1 Explanation: 1. When the client specifies a problem with breastfeeding, the best resource the nurse should inform the family about is the lactation consultant.

The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? 1. Check fetal heart tones. 2. Encourage the mother to go for a walk. 3. Change bed linens. 4. Call the physician.

Answer: 1 Explanation: 1. When the membranes rupture, the nurse notes the color and odor of the amniotic fluid and the time of rupture and immediately auscultates the FHR.

The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client? 1. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." 2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." 3. "What did you expect? You've only had contractions for a few hours. Labor takes time." 4. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."

Answer: 1 Explanation: 1. With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls.

During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? 1. The rise and fall of the chest 2. Sudden wakefulness 3. Urinary output 4. Adequate thermoregulation

Answer: 1 Explanation: 1. With proper resuscitation, chest movement is observed for proper ventilation. Pressure should be adequate to move the chest wall.

A 26-year-old client is having her initial prenatal appointment. The client reports to the nurse that she suffered a pelvic fracture in a car accident 3 years ago. The client asks whether her pelvic fracture might affect her ability to have a vaginal delivery. What response by the nurse is best? 1. "It depends on how your pelvis healed." 2. "You will need to have a cesarean birth." 3. "Please talk to your doctor about that." 4. "You will be able to delivery vaginally."

Answer: 1 Explanation: 1. Women with a history of pelvic fractures may also be at risk for cephalopelvic disproportion (CPD).

A client with diabetes is receiving preconception counseling. The nurse will emphasize that during the first trimester, the woman should be prepared for which of the following? 1. The need for less insulin than she normally uses 2. Blood testing for anemia 3. Assessment for respiratory complications 4. Assessment for contagious conditions

Answer: 1 Explanation: 1. Women with diabetes often require less insulin during the first trimester.

A couple in their late 30s are pregnant for the first time. In evaluating the care delivered, the nurse assesses the mother for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Makes appropriate healthcare choices 2. Receives effective healthcare through the pregnancy 3. Has a partner who is not interested in child care 4. Cannot cope with her life change 5. Wishes to have amniocentesis done

Answer: 1, 2 Explanation: 1. Expected outcomes of nursing care for a pregnant couple over 35 include that the client and her partner are knowledgeable about the pregnancy and make appropriate healthcare choices. 2. Expected outcomes of nursing care for a pregnant couple over 35 include the client and her partner receive effective health care throughout the pregnancy, birth, and postpartum period.

In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Volume of urine output 2. Weight 3. Blood pH 4. Head circumference 5. Bowel sounds

Answer: 1, 2 Explanation: 1. In order to assess hydration status, volume of urine output must be evaluated. 2. In order to assess hydration status, the infant's weight must be evaluated.

The nurse is evaluating the outcomes of nursing care for a woman with a urinary tract infection. Which of the following does the nurse include in the evaluation? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The client implements self-care measures for prevention. 2. The client completed the prescribed antibiotics. 3. The client knows self-care measures for worsening symptoms. 4. The client states that UTIs are controlled, not cured. 5. The client knows that cranberry juice can help prevent UTIs.

Answer: 1, 2 Explanation: 1. In the evaluation, the nurse should determine whether the client implements self-care measures to help prevent recurrent UTI as part of her personal routine. 2. Evaluation includes whether the client completed her prescribed course of antibiotic therapy.

A client at 32 weeks' gestation comes to the clinic with urinary burning and frequency. The nurse explains that urinary tract infections are common in pregnancy due to which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ureteral atonia 2. Stasis of urine 3. Increased glomerular filtration rate 4. Increased renal plasma flow 5. Increased clearance of urea

Answer: 1, 2 Explanation: 1. The presence of amino acids and glucose in the urine in conjunction with the tendency toward ureteral atonia and stasis of urine in the ureters may increase the risk of urinary tract infection. 2. The presence of amino acids and glucose in the urine in conjunction with the tendency toward ureteral atonia and stasis of urine in the ureters may increase the risk of urinary tract infection.

The nurse in the emergency department is admitting a 22-year-old woman who complains of watery diarrhea, dizziness, and vomiting. She is in the middle of her period, and has a tampon in place. The nurse suspects toxic shock syndrome, and assesses for the manifestations of which symptom? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Fever 2. Rash 3. Desquamation of skin 4. Bloating 5. Urinary frequency and urgency

Answer: 1, 2, 3 Explanation: 1. A fever presents initially. 2. A rash on the trunk presents initially. 3. The fever and rash on the trunk present initially, followed by desquamation of the skin, especially the palms and soles, which usually occurs 1 to 2 weeks after the onset of symptoms.

A client attending a prenatal class asks why episiotomies are performed. The nurse explains that risk factors that predispose women to episiotomies include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Large or macrosomic fetus 2. Use of forceps 3. Shoulder dystocia 4. Maternal health 5. Shorter second stage

Answer: 1, 2, 3 Explanation: 1. A large fetus places a woman at risk for an episiotomy to prevent lacerations. 2. Use of forceps or vacuum extractor is a risk factor that predisposes women to episiotomies. 3. Shoulder dystocia is a risk factor that predisposes women to episiotomies.

A cesarean section is ordered for the laboring client with whom the nurse has worked all shift. The client will receive general anesthesia. The nurse knows that potential complications of general anesthesia include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal depression that is directly proportional to the depth and duration of the anesthesia 2. Poor fetal metabolism of anesthesia, which inhibits use with preterm infants 3. Uterine relaxation 4. Increased gastric motility 5. Itching of the face and neck

Answer: 1, 2, 3 Explanation: 1. A primary danger of general anesthesia is fetal depression, because the medication reaches the fetus in about 2 minutes. The depression is directly proportional to the depth and duration of anesthesia. 2. The poor fetal metabolism of general anesthetic agents is similar to that of analgesic agents administered during labor. General anesthesia is not advocated when the fetus is considered to be at high risk, particularly in preterm birth. 3. Most general anesthetic agents cause some degree of uterine relaxation.

The nurse is providing health education to a group of young people. When teaching about the prevention of sexually transmitted infections (STIs), the nurse will teach which concepts? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Decision-making skills in refusing intercourse 2. How to reduce high-risk behaviors 3. That Pap smears might be needed more often 4. The safety of oral sex 5. Use of petroleum-based lubricants with condoms

Answer: 1, 2, 3 Explanation: 1. Effective prevention and control of STIs is based on planning ahead, review of decision-making skills, and developing strategies to refuse sex. 2. Effective prevention and control of STIs is based on the reduction of high-risk behaviors. Use of recreational drugs and alcohol can increase sexual risk taking. 3. The presence of a genital infection can lead to an abnormal Pap smear. Women with certain infections should have more frequent Pap tests.

The nurse is educating a group of women about the manifestations of benign breast conditions. What information topics will the nurse include? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Masses rapid in appearance or disappearance 2. Galactorrhea is common 3. Galactorrhea is seen with some psychiatric medications 4. Ulcerations or skin erosions are possible 5. An increased breast size with dimpling

Answer: 1, 2, 3 Explanation: 1. Fluctuations in size and rapid appearance or disappearance of breast masses are common in fibrocystic breasts. 2. Galactorrhea is a benign change often associated with hormone therapy. 3. Galactorrhea is often seen in women who have nursed, who have fibrocystic changes in the breast, or are on some types of psychiatric medication.

What are some of the advantages and disadvantages of formula-feeding that a nurse should discuss with new parents? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nutritional value of formula depends on the proper preparation/dilution. 2. There is a potential for bacterial contamination during preparation and storage. 3. Both parents can participate in positive parent-infant interaction during feeding. 4. Refrigeration is not necessary if preparing more than one bottle at a time. 5. Formula has higher levels of essential fatty acids, lactose, cystine, and cholesterol than does breast milk.

Answer: 1, 2, 3 Explanation: 1. Formula composition does not vary unless the instructions for preparation and dilution are not followed. 2. Bacteria can be introduced if bottles and nipples are not properly cleaned. 3. If a mother has chosen not to breastfeed, then the father can be involved with bottle feedings from the start.

The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Maternal exhaustion 2. Cervical edema 3. Tearing and bruising of the cervix 4. Enhanced perineal thinning 5. Having to perform an episiotomy

Answer: 1, 2, 3 Explanation: 1. If the cervix is not completely dilated, maternal exhaustion can occur. 2. If the cervix is not completely dilated, cervical edema can occur. 3. If the cervix is not completely dilated, tearing and bruising of the cervix can occur.

The nurse is caring for a client who could be at risk for uterine rupture. The nurse is monitoring the fetus closely for which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Late decelerations 2. Bradycardia 3. Loss of ability to determine fetal station 4. Tachycardia 5. Early decelerations

Answer: 1, 2, 3 Explanation: 1. Late decelerations could be seen with uterine rupture. 2. Bradycardia is seen if there is uterine rupture. 3. The uterus is not holding the fetus in place anymore if the uterus ruptures.

A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Shooting pain between breastfeedings 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Pain radiating to the underarm area from the breast

Answer: 1, 2, 3 Explanation: 1. Mastitis is characterized by shooting pain between feedings, often radiating to the chest wall. 2. Mastitis is characterized by late-onset nipple pain. 3. The skin of the affected breast becomes pink, flaking, and pruritic. Page Ref: 983

The partner of a pregnant client comes to the clinic with her. He complains to the nurse that he is experiencing different physical changes. The nurse determines he is experiencing couvade when he describes which symptoms? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Fatigue 2. Increased appetite 3. Headache 4. Backache 5. High anxiety level

Answer: 1, 2, 3, 4 Explanation: 1. Couvade is demonstrated by increased fatigue in the partner. 2. Couvade is demonstrated by an increased appetite in the partner. 3. Couvade is demonstrated by the partner's having headaches. 4. Couvade is demonstrated by the partner's experiencing backache.

The nurse is teaching about reproduction, and explains that which of the following are the purposes of meiosis? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Produce gametes 2. Reduce the number of chromosomes 3. Introduce genetic variability 4. Produce cells for growth and development 5. Divide somatic cells into new cells with identical characteristics

Answer: 1, 2, 3 Explanation: 1. Meiosis is a special type of cell division by which diploid cells give rise to gametes (sperm and ova). 2. The cells contain half the genetic material of the parent cell-only 23 chromosomes-the haploid number of chromosomes. 3. During meiosis new combinations of cells are provided by the newly formed chromosomes; these combinations account for the wide variation of traits.

The nurse is writing a care plan for a client with abnormal uterine bleeding (AUB). Which goals does the nurse include? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Preventing or treating anemia 2. Preventing endometrial hyperplasia 3. Restoring quality of life 4. Conducting pelvic exams monthly 5. Analyzing liver and kidney function

Answer: 1, 2, 3 Explanation: 1. One goal for the client with AUB is to prevent or treat anemia. 2. One goal for the client with AUB is to prevent endometrial hyperplasia. 3. One goal for a client with AUB is to restore quality of life.

A pregnant asthmatic client is being seen for her initial prenatal visit. The nurse knows that the fetal implications of maternal asthma include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Prematurity 2. Low birth weight 3. Hypoxia with maternal exacerbation 4. Congenital anomalies from the medications 5. Perinatal transfer of the asthma

Answer: 1, 2, 3 Explanation: 1. One implication of maternal asthma is that the infant is at risk for prematurity. 2. One implication of maternal asthma is that the infant is at risk for low birth weight. 3. One implication of maternal asthma is that the infant is at risk for hypoxia if the mother has an exacerbation of her asthma.

The OB-GYN nurse works in a clinic with a culturally diverse group of clients whose specific actions during pregnancy are often determined by cultural beliefs. The nurse recognizes that these beliefs about pregnancy and childbirth fall into which categories? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Prescriptive beliefs 2. Restrictive beliefs 3. Taboos 4. Cultural humility 5. Folk treatment beliefs

Answer: 1, 2, 3 Explanation: 1. Prescriptive beliefs or requirements describe expected behaviors. 2. Restrictive beliefs are stated negatively and limit behaviors. 3. Taboo beliefs refer to specific supernatural consequences.

The nurse has assessed a client who is to undergo gynecological surgery. Upon what will the nurse base the nursing diagnosis? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The client's attitudes toward motherhood 2. The client's body image 3. The client's attitudes about sexuality 4. The client's long-term risk reduction 5. The client's use of acupuncture

Answer: 1, 2, 3 Explanation: 1. Reproductive surgery may also be seen as a threat to femininity in any social or cultural group that emphasizes childbearing and motherhood. 2. Surgery to alter or remove reproductive organs may be perceived as a threat to self-concept. Body image is affected whenever a body part is lost. 3. Many women fear postoperative changes such as masculinization, weight gain, loss of sexuality, and permanent loss of the ability to have a child.

Which findings would the nurse expect when assessing a newborn infected with syphilis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age

Answer: 1, 2, 3 Explanation: 1. Rhinitis is evident in the newborn exposed to syphilis. 2. Fissures on mouth corners and an excoriated upper lip indicate exposure to syphilis. 3. A red rash around the mouth and anus is observed.

The clinic nurse is culturally sensitive when, while assessing the pregnant client, he asks about which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The family's expectations of the healthcare system 2. Which cultural practices should be incorporated into care 3. Any alternative healer who should be consulted 4. Positive consequences of the client's healthcare beliefs 5. The client's giving up her practices and adopting the practices of the dominant culture

Answer: 1, 2, 3 Explanation: 1. The nurse needs to ask about the client's expectations of the healthcare system. 2. The nurse should ask about any cultural or spiritual practices that should be incorporated into care. 3. The culturally sensitive nurse will ask whether any alternative healer should be consulted about care.

The nurse is teaching a group of young women how to prevent urinary tract infections. What will the nurse include in the teaching? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The importance of good hygiene 2. How to recognize the signs and symptoms 3. How to take prescribed antibiotics 4. Fluids are restricted to 1000 ml 5. To urinate only when the urge is strong

Answer: 1, 2, 3 Explanation: 1. The nurse should make sure that women are aware of good hygiene practices, and should provide information on other ways to avoid UTI. 2. Women need to know the signs and symptoms of UTIs to secure prompt treatment. 3. If an infection is present, the woman needs information on how to take antibiotics, and needs to know to complete all of them.

Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? 1. Mediolateral 2. Episiorrhaphy 3. Midline 4. Medical

Answer: 3 Explanation: 3. Major perineal trauma is more likely to occur if a midline episiotomy is performed. The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum.

What self-care measures would a nurse recommend for a client in her first trimester to reduce the discomfort of nausea and vomiting? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Avoid odors or causative factors. 2. Have small but frequent meals. 3. Drink carbonated beverages. 4. Drink milk before arising in the morning. 5. Eat highly seasoned food.

Answer: 1, 2, 3 Explanation: 1. The nurse would recommend for a client in her first trimester to avoid odors and caustic factors to reduce the discomfort of nausea and vomiting. 2. The nurse would recommend for a client in her first trimester to have small but frequent meals to reduce the discomfort of nausea and vomiting. 3. The nurse would recommend for a client in her first trimester to drink carbonated beverages to reduce the discomfort of nausea and vomiting.

The prenatal period should be used to expose the prospective parents to up-to-date, evidence-based information about which of the following topics? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Breastfeeding 2. Pain relief 3. Obstetric complications and procedures 4. Toddler care 5. Antepartum adjustment

Answer: 1, 2, 3 Explanation: 1. The prenatal period should expose prospective parents to up-to-date, evidence-based information about breastfeeding. 2. The prenatal period should expose prospective parents to up-to-date, evidence-based information about pain relief. 3. The prenatal period should expose prospective parents to up-to-date, evidence-based information about obstetric complications and procedures.

The nurse is working with a pregnant woman who has systemic lupus erythematosus (SLE). What does the nurse anticipate the infant might be born with? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. A tendency to bleed excessively 2. An increased chance of developing infections 3. A hemoglobin less than optimal for good health 4. Problems with vision 5. Hearing loss

Answer: 1, 2, 3 Explanation: 1. This is true, as the infant might be born with thrombocytopenia. 2. This is true, as the infant might be born with neutropenia. 3. This is true, as the infant might be born with anemia.

A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Avoid crossing the legs. 2. Avoid prolonged standing or sitting. 3. Take frequent walks. 4. Take a daily aspirin dose of 650 mg. 5. Avoid long car trips.

Answer: 1, 2, 3 Explanation: 1. Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. 2. Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. 3. Women should be advised to avoid a sedentary lifestyle and to exercise as much as possible (walking is ideal).

The nurse is discharging a client after hospitalization for pelvic inflammatory disease (PID). Which statements indicate that teaching was effective? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. "I might have infertility because of this infection." 2. "It is important for me to finish my antibiotics." 3. "Tubal pregnancy could occur after PID." 4. "My PID was caused by a yeast infection." 5. "I am going to have an IUD placed for contraception."

Answer: 1, 2, 3 Explanation: 1. Women sometimes become infertile because of scarring in the fallopian tubes as a result of the inflammation of PID. 2. Antibiotic therapy should always be completed when a client is diagnosed with any infection. 3. The tubal scarring that occurs from tubal inflammation during PID can prevent a fertilized ovum from passing through the tube into the uterus, causing an ectopic or tubal pregnancy.

The nurse caring for a client in labor anticipates fetal macrosomia and shoulder dystocia. Appropriate management of shoulder dystocia is essential in order to prevent which fetal complications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Brachial plexus injury 2. Fractured clavicle 3. Asphyxia 4. Neurological damage 5. Puerperal infection

Answer: 1, 2, 3, 4 Explanation: 1. Brachial plexus injury occurs due to improper or excessive traction applied to the fetal head. 2. Complications in macrosomia include fractured clavicles. 3. Complications in macrosomia include asphyxia of the fetus. 4. Neurological damage is a complication of macrosomia.

The nurse is planning a home visit for a new mother and newborn who were discharged prior to 48 hours after delivery. In preparation for the home visit, what should the nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Review the client's records. 2. Gather materials and equipment that might be needed. 3. Make a pre-visit telephone call to determine time and day of visit. 4. Contact the healthcare provider about any special concerns. 5. Schedule additional home visits or follow-up contacts with community agencies.

Answer: 1, 2, 3, 4 Explanation: 1. Communication with the primary healthcare provider(s) and a thorough review of inpatient records give the nurse an understanding of current needs and any special concerns for each individual mother-baby couplet. 2. Before the home visit, the nurse prepares by identifying the purpose of the visit and gathering anticipated materials and equipment. 3. The nurse should make a previsit telephone call to arrange the appointment with the woman and her family. 4. Communication with the primary healthcare provider(s) and a thorough review of inpatient records give the nurse an understanding of current needs and any special concerns for each individual mother-baby couplet.

The nurse is working with a woman who abuses stimulants. The nurse is aware that the fetus is at risk for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Withdrawal symptoms 2. Cardiac anomalies 3. Sudden infant death syndrome 4. Being small for gestational age 5. Fetal alcohol syndrome

Answer: 1, 2, 3, 4 Explanation: 1. Infants born to mothers who abuse stimulants such as amphetamines can have withdrawal symptoms. 2. Infants born to mothers who abuse stimulants such as cocaine can be born with cardiac anomalies. 3. Infants born to mothers who abuse stimulants such as cocaine can have sudden infant death syndrome. 4. Infants born to mothers who abuse stimulants such as nicotine can be small for gestational age.

When teaching the new mother about the composition of breast milk, the nurse explains that the fat content can range from 30 to 50 grams/liter. Which factors affect the fat content of breast milk? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal parity 2. Duration of pregnancy 3. Stage of lactation 4. Time of day 5. Vitamin C intake

Answer: 1, 2, 3, 4 Explanation: 1. Multiparous mothers produce milk with a lower content of fatty acids than primigravidas. 2. The milk of a mother who delivers a preterm infant has a greater concentration of DHA and ARA than does the milk of a mother who gives birth to a full-term infant. 3. Phospholipids and cholesterol levels are higher in colostrum than in mature milk, although overall fat content is higher in mature breast milk than in colostrum. 4. Fat content is generally higher in the evening and lower in the early morning.

A client is diagnosed with a cystocele. The nurse actively listens as the client talks about which treatment choice to make. The treatment options available to the client are which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Kegel exercises 2. Vaginal pessaries 3. Surgical intervention 4. Estrogen 5. Fine-needle aspiration

Answer: 1, 2, 3, 4 Explanation: 1. One treatment option is to use Kegel exercises. 2. A treatment choice the client has is to have a pessary or ring inserted. 3. Surgical intervention is one approach to helping the client with a cystocele. 4. Estrogen may improve the condition of vaginal mucous membranes, especially in menopausal women.

The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Prematurity 2. Maternal intrapartum fever 3. Membranes ruptured for longer than 18 hours 4. A previously infected infant with GBS disease 5. An older mother having her first baby

Answer: 1, 2, 3, 4 Explanation: 1. Prematurity is a risk factor. 2. Maternal intrapartum fever is a risk factor. 3. Prolonged rupture of membranes is a risk factor. 4. A previously infected infant increases the risk.

Characteristics of a caring relationship that the nurse cultivates when interacting with the client in the home include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Regard for the client 2. Genuineness 3. Empathy 4. Rapport 5. Attachment

Answer: 1, 2, 3, 4 Explanation: 1. Showing regard to the client by introducing oneself and calling the client by name helps demonstrate a positive regard for the client. 2. The nurse displays genuineness by meaning what he says, conveying verbal and nonverbal messages that are congruent, and being nonjudgmental. 3. The nurse needs to listen to the client without judgment and to try to view events from the client's point of view. 4. Trust and rapport is established by doing what you say will you do, being prepared for the visit and being on time, and following up on any areas that are needed.

What assessments of the newborn should be completed during the initial home visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sleep-wake cycles 2. Parent-infant interaction 3. Fontanelles 4. Umbilical cord status 5. Breast engorgement

Answer: 1, 2, 3, 4 Explanation: 1. The infant's sleep-wake cycles need to be assessed. 2. It is important to assess whether the parent is beginning to attach and bond to the infant. 3. The infant's fontanelles should be assessed. 4. The umbilical cord stump should show no signs of infection.

The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs' test 5. Cord serum OgM

Answer: 1, 2, 3, 4 Explanation: 1. The initial laboratory workup for anemia should include hemoglobin measurements. 2. The initial laboratory workup for anemia should include hematocrit measurements. 3. The initial laboratory workup for anemia should include a reticulocyte count. 4. The direct Coombs' test reveals the presence of antibody-coated (sensitized) Rh-positive red blood cells in the newborn and should be included in the initial laboratory workup for anemia.

What are the nurse's responsibilities when teaching the new mother about infant feeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nurse should be well informed about infant nutrition and feeding methods. 2. The nurse should provide accurate and consistent information. 3. The nurse should use each interaction to support the parents and promote the family's sense of confidence. 4. The nurse should familiarize the mother with information about community resources that might be helpful after discharge. 5. The nurse should aggressively promote breastfeeding, even if the parents have decided to bottle-feed their infant.

Answer: 1, 2, 3, 4 Explanation: 1. The nurse should provide information on maternal and infant nutrition, fluid requirements, and feeding methods. 2. The nurse should provide information that is accurate and consistent. Nurses have a responsibility to educate parents. 3. Every interaction is a chance to educate and support the new parents in learning how to care for the newborn. Nurses have a responsibility to educate parents. 4. It is important that parents receive verbal and written instructions and community resource information to which they can later refer.

A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? 1. Active 2. Transition 3. Latent 4. Second

Answer: 2 Explanation: 2. During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety.

The nurse educator is presenting a class on the different kinds of miscarriages. Miscarriages, or spontaneous abortions, are classified clinically into which of the following different categories? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Threatened abortion 2. Incomplete abortion 3. Complete abortion 4. Missed abortion 5. Acute abortion

Answer: 1, 2, 3, 4 Explanation: 1. Unexplained cramping, bleeding, or backache indicates the fetus might be in jeopardy. This is a threatened abortion. 2. In an incomplete abortion, parts of the products of conception are retained, most often the placenta. 3. In a complete abortion, all the products of conception are expelled. The uterus is contracted and the cervical os may be closed. 4. In a missed abortion, the fetus dies in utero but is not expelled.

During a visit to the obstetrician, a pregnant client questions the nurse about the potential need for an amniotomy. The nurse explains that an amniotomy is performed to do which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Stimulate the beginning of labor 2. Augment labor progression 3. Allow application of an internal fetal electrode 4. Allow application of an external fetal monitor 5. Allow insertion of an intrauterine pressure catheter

Answer: 1, 2, 3, 5 Explanation: 1. Amniotomy is the artificial rupture of the amniotic membranes and can be used to induce labor. 2. Amniotomy can be done to augment labor. 3. Amniotomy allows access to the fetus in order to apply an internal fetal electrode to the fetal scalp. 5. Amniotomy may be performed during labor to allow an intrauterine pressure catheter to be inserted.

During home care of a low-risk pregnant client, the nurse provides care by assessing which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Urine 2. Weight 3. Diet 4. Pelvic measurements 5. Physical activity

Answer: 1, 2, 3, 5 Explanation: 1. Assessment of the client's urine can be done in the home setting. 2. Obtaining the client's weight can be done in the home setting. 3. Assessing the client's dietary intake can be done in the home setting. 5. The client's physical activity can be assessed in the home setting.

Childbirth preparation offers several advantages including which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. It helps a pregnant woman and her support person understand the choices in the birth setting. 2. It promotes awareness of available options. 3. It provides tools for a pregnant woman and her support person to use during labor and birth. 4. Women who receive continuous support during labor require more analgesia, and have more cesarean and instrument births. 5. Each method has been shown to shorten labor.

Answer: 1, 2, 3, 5 Explanation: 1. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. 2. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. 3. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. 5. Childbirth preparation offers several advantages. Each method has been shown to shorten labor.

When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal heart rate 2. Blood pressure 3. Temperature 4. Urine color 5. Pulse and respirations

Answer: 1, 2, 3, 5 Explanation: 1. Determine the fetal heart rate along with blood pressure, or monitor continuously with the electronic fetal monitor if the situation indicates. 2. Determine blood pressure every 1 to 4 hours, or more frequently if indicated by medication or other changes in the woman's status. 3. Determine temperature every 4 hours, or every 2 hours if elevated or if premature rupture of the membranes (PROM) has occurred. 5. Determine pulse rate and respirations along with blood pressure.

The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Prolonged labor 2. Difficult birth 3. Full bladder 4. Breastfeeding 5. Infection

Answer: 1, 2, 3, 5 Explanation: 1. During prolonged labor, the muscles relax because of prolonged time of contraction during labor. 2. During a difficult birth, the uterus is manipulated excessively, causing fatigue. 3. As the uterus is pushed up and usually to the right, pressure on a full bladder interferes with effective uterine contraction. 5. Inflammation and infection interfere with uterine muscle's ability to contract effectively.

For what common side effects of epidural anesthesia should the nurse watch? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Elevated maternal temperature 2. Urinary retention 3. Nausea 4. Long-term back pain 5. Local itching

Answer: 1, 2, 3, 5 Explanation: 1. Elevated maternal temperature is a potential side effect of epidural anesthesia. 2. Urinary retention is a potential side effect of epidural anesthesia. 3. Nausea is a potential side effect of epidural anesthesia. 5. Pruritus may occur at any time during the epidural infusion. It usually appears first on the face, neck, or torso and is generally the result of the agent used in the epidural infusion. Benadryl, an antihistamine, can be administered to manage pruritus.

) In caring for a client with a uterine rupture, the nurse determines which nursing diagnoses to be appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Gas Exchange, Impaired 2. Fear related to unknown outcome 3. Coping, Ineffective 4. Mobility: Physical, Impaired 5. Anxiety

Answer: 1, 2, 3, 5 Explanation: 1. Gas Exchange, Impaired diagnosis could apply to both mother and fetus. 2. The client would experience fear related to an unknown outcome. 3. Ineffective coping would be due to emergent situation secondary to uterine rupture. 5. There will be anxiety related to emergency procedures and unknown fetal outcome.

Which interventions can the nurse utilize to provide continuity of care for the postpartal client who experienced a complication and is now ready to return home? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Encourage the client to take advantage of home visits. 2. Make telephone calls as a follow-up to check on the client and newborn. 3. Provide information about postpartal support groups. 4. Refer to mental health professionals to help screen the client for any mental health problems as a result of the complications experienced in the hospital. 5. Supply information about postpartum expectations designed to meet the specific needs of a variety of families.

Answer: 1, 2, 3, 5 Explanation: 1. Home visits, especially for early discharge families, are invaluable in fostering positive adjustments for the new family. 2. Telephone follow-up at 2 to 3 weeks postpartum to ask whether the mother is experiencing difficulties is also helpful. 3. Support groups in which child care is available can be an invaluable community service for the postpartum client. 5. Social support teaching guides are available to assist in helping postpartum women explore their needs for postpartum support.

Which of the following symptoms, if progressive, are indicative of CHF, the heart's signal of its decreased ability to meet the demands of pregnancy? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Palpitations 2. Heart murmurs 3. Dyspnea 4. Frequent urination 5. Rales

Answer: 1, 2, 3, 5 Explanation: 1. Palpitations are indicative of CHF. 2. Heart murmurs are indicative of CHF. 3. Dyspnea is indicative of CHF. 5. Rales are indicative of CHF.

At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Anticipatory guidance about the realities of being a parent. 2. Parenting literature and reference manuals. 3. Phone numbers and locations of local parenting groups. 4. Referral for specialized interventions related to postpartum blues. 5. Phone numbers and names of postpartum doulas.

Answer: 1, 2, 3, 5 Explanation: 1. Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles. 2. Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles. 3. New mother support groups are helpful for women who lack a social support system. 5. Postpartum doulas are professionals trained to help the new mother after the birth of the baby.

) The nurse has completed the physical assessment of a client in early labor, and proceeds with the social assessment. A social history of the client would include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use of drugs and alcohol 2. Family violence or sexual assault 3. Current living situation 4. Type of insurance 5. Availability of resources

Answer: 1, 2, 3, 5 Explanation: 1. Risk factors such as the use of drugs or alcohol during the pregnancy can influence the labor and birth. 2. It is imperative to ask the woman about domestic violence and to assess any degree of psychologic or physical harm, either potential or real. 3. A social assessment includes asking about the woman's current living situation. This dialog provides an opportunity for the nurse to continue to build support, to provide information when requested, and to be direct yet supportive. 5. A social assessment includes asking about resources available to the family.

The nurse is teaching the significance of good nutrition on fetal development to a group of young women. What factors will the nurse discuss? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Vitamins and folic acid are important before conception. 2. Maternal nutrition may predispose to the development of adult coronary heart disease, hypertension, and diabetes. 3. Glucose, amino acids, and fatty acids are of high importance. 4. Nutrition is important only during the first trimester. 5. Maternal nutrition can affect brain and neural tube development.

Answer: 1, 2, 3, 5 Explanation: 1. Vitamins and folic acid supplements taken before conception can reduce the incidence of neural tube defects. 2. This is true. Maternal nutrition may predispose to the development of adult coronary heart disease, hypertension, and diabetes. 3. Amino acids, glucose, and fatty acids are considered to be the primary dietary factors in brain growth. 5. Adequacy of the maternal environment is also important during the periods of rapid embryonic and fetal development. Maternal nutrition can affect brain and neural tube development.

A prenatal client asks the nurse about conditions that would necessitate a cesarean delivery. The nurse explains that cesarean delivery generally is performed in the presence of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Complete placenta previa 2. Placental abruption 3. Umbilical cord prolapse 4. Precipitous labor 5. Failure to progress

Answer: 1, 2, 3, 5 Explanation: 1. When the placenta completely covers the uterine opening, a cesarean is performed. 2. Premature separation of the placenta from the uterine wall requires an immediate cesarean. 3. A prolapsed cord is an emergency requiring an immediate cesarean. 5. Failure to progress in labor can necessitate a cesarean birth.

A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Restlessness 2. Pain 3. Kidney distention 4. Adequacy of fluid intake 5. Lethargy

Answer: 1, 2, 4 Explanation: 1. A newborn who has not voided by 48 hours after birth should be assessed for restlessness. 2. A newborn who has not voided by 48 hours after birth should be assessed for pain. 4. A newborn who has not voided by 48 hours after birth should be assessed for adequacy of fluid intake.

Premonitory signs of labor include which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Braxton Hicks contractions 2. Cervical softening and effacement 3. Weight gain 4. Rupture of membranes 5. Sudden loss of energy

Answer: 1, 2, 4 Explanation: 1. A premonitory sign of labor includes Braxton Hicks contractions. 2. A premonitory sign of labor includes cervical softening and effacement. 4. A premonitory sign of labor includes rupture of membranes.

The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Bulging perineum 2. Increased bloody show 3. Spontaneous rupture of the membranes 4. Uncontrollable urge to push 5. Inability to breathe through contractions

Answer: 1, 2, 4 Explanation: 1. As the fetal head continues its descent, the perineum begins to bulge, flatten, and move anteriorly. 2. Bloody show increases as a woman enters the second stage of labor. 4. As the fetal head descends, the woman has the urge to push because of pressure of the fetal head on the sacral and obturator nerves.

The OB-GYN nurse knows that the proliferative phase of the menstrual cycle includes which changes? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Thin, clear cervical mucus 2. Estrogen peaks just before ovulation 3. No ferning pattern of cervical mucus 4. A pH change to 7.5 5. Epithelium warps into folds

Answer: 1, 2, 4 Explanation: 1. Cervical mucus at ovulation becomes thin, clear, watery, and more alkaline, making it more favorable to spermatozoa. 2. Estrogen peaks just before ovulation in the proliferative phase of the menstrual cycle. 4. The cervical mucosa pH increases from below 7 to 7.5 at the time of ovulation.

Marked changes occur in the cardiopulmonary system at birth include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Closure of the foramen ovale 2. Closure of the ductus venosus 3. Mean blood pressure of 31 to 61 mmHg in full-term resting newborns 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance 5. Opening of the ductus arteriosus

Answer: 1, 2, 4 Explanation: 1. Closure of the foramen ovale is a function of changing arterial pressures. 2. Closure of the ductus venosus is related to mechanical pressure changes that result from severing the cord, redistribution of blood, and cardiac output. 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance; with the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. The combination of vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance.

Risk factors for tachysystole include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cocaine use 2. Placental abruption 3. Low-dose oxytocin titration regimens 4. Uterine rupture 5. Smoking

Answer: 1, 2, 4 Explanation: 1. Cocaine use is a risk factor for tachysystole. 2. Placental abruption is a risk factor for tachysystole. 4. Uterine rupture is a risk factor for tachysystole.

A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to the parents. Which factors would the nurse include in the explanation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. At birth, the newborn's liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. 2. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. 3. Unconjugated bilirubin results from the destruction of white blood cells. 4. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin. 5. The newborn's liver has greater metabolic and enzymatic activity at birth than does an adult liver, increasing the newborn's susceptibility to jaundice.

Answer: 1, 2, 4 Explanation: 1. Conjugation, or the changing of bilirubin into an excretable form, is the conversion of the yellow lipid-soluble pigment (unconjugated, indirect) into water-soluble pigment (excretable, direct). 2. Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. 4. Unconjugated bilirubin is fat soluble, has a propensity for fatty tissues, is not in an excretable form, and is a potential toxin.

The client is undergoing an emergency cesarean birth for fetal bradycardia. The client's partner has not been allowed into the operating room. What can the nurse do to alleviate the partner's emotional distress? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Allow the partner to wheel the baby's crib to the newborn nursery. 2. Allow the partner to be near the operating room where the newborn's first cry can be heard. 3. Have the partner wait in the client's postpartum room. 4. Encourage the partner to be in the nursery for the initial assessment. 5. Teach the partner how to take the client's blood pressure.

Answer: 1, 2, 4 Explanation: 1. Effective measures include allowing the partner to take the baby to the nursery. 2. Effective measures include allowing the partner to be in a place near the operating room, where the newborn's first cry can be heard. 4. Effective measures include involving the partner in postpartum care in the recovery room.

A full-term infant has just been born. Which interventions should the nurse perform first? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Placing the infant in a radiant-heated unit 2. Suctioning the infant with a bulb syringe 3. Wrapping the infant in a blanket 4. Evaluating the newborn using the Apgar system 5. Offering a feeding of 5% glucose water

Answer: 1, 2, 4 Explanation: 1. If the newborn is placed in a radiant-heated unit, he or she is dried, laid on a dry blanket, and left uncovered under the radiant heat. 2. Newborns are suctioned with a bulb syringe to clear mucus from the newborn's mouth. 4. The purpose of the Apgar score is to evaluate the physical condition of the newborn at birth.

The nurse is teaching an infertile couple about the causes of infertility. The nurse tells them that infertility can be caused by which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Immunological responses 2. Congenital anomalies 3. Patent fallopian tubes 4. Hypothyroidism 5. Favorable cervical mucus

Answer: 1, 2, 4 Explanation: 1. Immunological responses, such as antisperm antibodies, can cause infertility. 2. Congenital anomalies, such as a septate uterus, can cause infertility. 4. Hypothyroidism is a cause of infertility.

Which strategies would the nurse utilize to promote culturally competent care for the postpartum client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Examine one's own cultural beliefs, biases, stereotypes, and prejudices. 2. Respect the values and beliefs of others. 3. Limit the alternative food choices offered clients to minimize conflicts. 4. Incorporate the family's cultural practices into the care. 5. Evaluate whether the family's cultural practices fit into Western norms.

Answer: 1, 2, 4 Explanation: 1. It is important for nurses to recognize that they are approaching their patient's care from their own perspective and that, to individualize care for each mother, they need to assess the woman's preferences, her level of acculturation and assimilation to Western culture, her linguistic abilities, and her educational level. 2. It is important for nurses to recognize that they are approaching their patient's care from their own perspective and that, to individualize care for each mother, they need to assess the woman's preferences, her level of acculturation and assimilation to Western culture, her linguistic abilities, and her educational level. 4. The nurse should have the mother exercise her choices when possible and support those choices, with the help of cultural awareness and a sound knowledge base.

The client with polycystic ovarian syndrome (PCOS) has been prescribed metformin (Glucophage). The nurse tells the client that the medication will do which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Decrease your excessive hair growth." 2. "Make it easier to lose weight." 3. "Increase your acne." 4. "Improve your chances of pregnancy." 5. "Make your menstrual periods irregular."

Answer: 1, 2, 4 Explanation: 1. Polycystic ovarian syndrome (PCOS) treatment with metformin decreases hirsutism. 2. Polycystic ovarian syndrome (PCOS) treatment with metformin improves weight loss success. 4. Polycystic ovarian syndrome (PCOS) treatment with metformin increases ovulation and therefore menstrual regularity and fertility.

The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Providing a pacifier 2. Stroking the head 3. Restraining both arms and legs 4. Talking to the infant 5. Giving the infant a sedative before the procedure

Answer: 1, 2, 4 Explanation: 1. Providing a pacifier is an accepted method of soothing during the circumcision. 2. Stroking the head is an accepted method of soothing during the circumcision. 4. Talking to the infant is an accepted method of soothing during the circumcision.

The nurse has written the nursing diagnosis Injury, Risk for for a diabetic pregnant client. Interventions for this diagnosis include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Assessment of fetal heart tones 2. Perform oxytocin challenge test, if ordered 3. Refer the client to a diabetes support group 4. Assist with the biophysical profile assessment 5. Develop an appropriate teaching plan

Answer: 1, 2, 4 Explanation: 1. Reassuring fetal heart rate variability and accelerations are interpreted as adequate placental oxygenation. 2. The nurse would perform oxytocin challenge test (OCT)/contraction stress test (CST) and non-stress tests as determined by physician. 4. The nurse assists the physician in performing a biophysical profile assessment.

Which of the following are specific culturally sensitive nursing considerations the nurse integrates into care of the pregnant client? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Counseling about home remedies 2. Discussing components of a balanced diet 3. Refusing to discuss birthing choices 4. Encouraging use of support systems 5. Instructing the client to use no home remedies

Answer: 1, 2, 4 Explanation: 1. The culturally sensitive nurse should find out what medications and home remedies the client is using, and counsel the client regarding overall effects. 2. The culturally sensitive nurse will discuss the importance of a well-balanced diet during pregnancy with consideration of the client's cultural beliefs and practices. 4. Encouraging the use of support systems and spiritual aids that provide comfort for the mother is important in culturally sensitive care.

What are the three functions of the fallopian tubes? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Provide transport for the ovum from the ovary to the uterus 2. Serve as a warm, moist, nourishing environment for the ovum or zygote 3. Secrete large amounts of estrogens 4. Provide a site for fertilization to occur 5. Support and protect the pelvic contents

Answer: 1, 2, 4 Explanation: 1. The fallopian tubes provide transport for the ovum from the ovary to the uterus. 2. The fallopian tubes serve as a warm, moist, nourishing environment for the ovum or zygote. 4. The fallopian tubes provide a site for fertilization to occur.

The nurse is evaluating the outcomes of nursing care given a female client with a sexually transmitted infection (STI). Which of the following will the nurse verify about the client? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Had an identified infection 2. Could identify the mode of transmission 3. Would never cope with the infection 4. Could recognize the symptoms of an STI 5. Would not disclose the STI to her partner

Answer: 1, 2, 4 Explanation: 1. The infection must be identified and cured, if possible. If not, supportive therapy is provided. 2. The client and her partner should be able to describe the infection, its method of transmission, its implications, and the therapy. 4. The client must be able to recognize the symptoms of an STI.

The nurse educator is teaching student nurses what a fetus will look like at various weeks of development. Which descriptions would be typical of a fetus at 20 weeks' gestation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The fetus has a body weight of 435-465 g. 2. Nipples appear over the mammary glands. 3. The kidneys begin to produce urine. 4. Nails are present on fingers and toes. 5. Lanugo covers the entire body.

Answer: 1, 2, 4, 5 Explanation: 1. A fetus at 20 weeks' gestation has a body weight of 435-465 g. 2. A fetus at 20 weeks' gestation has nipples appear over the mammary glands. 4. A fetus at 20 weeks' gestation nails are present on fingers and toes. 5. A fetus at 20 weeks' gestation has lanugo that covers the entire body.

The nurse is presenting a class on the pathophysiology of the different abortions. Some of the causes are which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Chromosomal abnormalities 2. Insufficient or excessive hormonal levels 3. Sexual intercourse in the first trimester 4. Infections in the first trimester 5. Cervical insufficiency

Answer: 1, 2, 4, 5 Explanation: 1. Chromosomal defects are generally seen as spontaneous abortions during weeks 4 to 8. 2. Insufficient or excessive hormonal levels usually will result in spontaneous abortion by 10 weeks' gestation. 4. Infectious and environmental factors may also be seen in first trimester pregnancy loss. 5. In late spontaneous abortion, the cause is usually a maternal factor, for example, cervical insufficiency or maternal disease, and fetal death may not precede the onset of abortion.

The nurse is evaluating the plan of care for a pregnant client with a heart disorder. The nurse concludes that the plan was successful when data indicate which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The client gave birth to a healthy baby. 2. The client did not develop congestive heart failure. 3. The client developed thromboembolism. 4. The client identified manifestations of potential complications. 5. The client can identify her condition and its impact on her pregnancy, labor and birth, and postpartum period.

Answer: 1, 2, 4, 5 Explanation: 1. Giving birth to a healthy baby is an expected outcome of the pregnancy. 2. An expected outcome is that the woman does not develop congestive heart failure, thromboembolism, or infection. 4. An expected outcome is that the woman is able to identify potential complications and notify the healthcare provider. 5. The woman must be able to discuss her condition and its possible impact on her pregnancy, labor and birth, and the postpartum period.

The nurse is assessing a client before administering an analgesic. What are some of the factors the nurse should consider? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The client is willing to receive medication after being advised about it. 2. The client's vital signs are stable. 3. The partner agrees to use of the medication. 4. The client has no known allergies to the medication. 5. The client is aware of the contraindications of the medication.

Answer: 1, 2, 4, 5 Explanation: 1. Medication should be explained to the client before it is administered. 2. Vital signs need to be stable before any analgesic medication is administered. 4. Ask the client about allergies before administering any medications. 5. Clients should always be aware of the contraindications of the medication.

When providing anticipatory guidance to a new mother, what information does the nurse convey about the newborn's neurologic and sensory/perceptual functioning? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. 2. The usual position of the newborn is with extremities partially flexed, legs near the abdomen. 3. Newborns do not react to bright light, and their eye movements do not permit them to fixate on faces or objects until they are 3 months of age. 4. Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held.

Answer: 1, 2, 4, 5 Explanation: 1. Newborns respond to and interact with the environment in a predictable pattern of behavior that is shaped somewhat by their intrauterine experience. 2. Normal newborns are usually in a position of partially flexed extremities with the legs near the abdomen. 4. Self-quieting ability is the ability of newborns to use their own resources to quiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held; thus touch may be the most important of all of the senses for the newborn infant.

When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Ask the client to void before assessing the uterus. 2. Inform the client of the need for regular assessments. 3. Defer client teaching to another time. 4. Perform the procedures as gently as possible. 5. Take precautions to prevent exposure to body fluids.

Answer: 1, 2, 4, 5 Explanation: 1. Palpating the fundus when the woman has a full bladder may give false information about the progress of involution. Ask the woman to void before assessment. 2. The nurse should provide an explanation of the purposes of regular assessment to the woman. 4. The woman should be relaxed before starting, and procedures should be performed as gently as possible, to avoid unnecessary discomfort. 5. Gloves should be worn before starting the assessment.

Which findings would indicate the presence of a perineal wound infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Redness 2. Tender at the margins 3. Vaginal bleeding 4. Hardened tissue 5. Purulent drainage

Answer: 1, 2, 4, 5 Explanation: 1. Redness is a classic sign of a perineal wound infection. 2. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 4. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 5. Purulent drainage is a classic signs of a perineal wound infection.

The nurse is talking with a couple who have been trying to get pregnant for 5 years. They are now at the fertility clinic seeking help. The nurse assesses their emotional responses as part of the workup. Which responses would the nurse expect to hear? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Experiencing a sense of loss of status 2. Feelings of failure because they cannot make a baby 3. Healthy relationship with healthcare partners 4. Stress on the marital and sexual relationship 5. Feelings of frustration

Answer: 1, 2, 4, 5 Explanation: 1. The couple may experience feelings of loss of status and ambiguity as a couple. 2. Feelings of failure are common. 4. The couple may experience stress on the marital and sexual relationship. 5. Tests and treatments may heighten feelings of frustration or anger between partners.

The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Measure head circumference daily. 2. Assess for bulging fontanelles. 3. Avoid position changes. 4. Watch for signs of infection. 5. Use a gel pillow under the head.

Answer: 1, 2, 4, 5 Explanation: 1. The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day. 2. The infant has congenital hydrocephalus. Fontanelles should be checked for bulging and sutures for widening. 4. Infants with hydrocephalus are prone to infection. 5. The infant has congenital hydrocephalus. The enlarged head should be supported with a gel pillow.

A mother and her newborn have been discharged after a hospital stay of less than 48 hours. What are essential components the nurse must include in the first postpartum home visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assessment of color 2. Measurement of weight 3. Measurement of height 4. Assessment of mother-newborn interaction 5. Reinforcement of information about feeding and sleep patterns

Answer: 1, 2, 4, 5 Explanation: 1. The nurse should assess the newborn's general health, hydration, and degree of jaundice. 2. The nurse should weigh the infant. 4. This is an opportune time to assess the quality of mother-newborn interaction and details of newborn behavior. 5. Parents frequently need further clarification and reinforcement of maternal or family education in neonatal care, particularly feeding and sleep position.

Remedies for back pain in pregnancy that are supported by research evidence and may safely be taught to any pregnant woman by the nurse include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pelvic tilt 2. Water aerobics 3. Sit-ups 4. Proper body mechanics 5. Maintaining good posture

Answer: 1, 2, 4, 5 Explanation: 1. The pelvic tilt can help restore proper body alignment and relieve back pain. 2. Exercise is an effective treatment for lower back pain. Exercise in water seems to provide benefits while being physically comfortable for expectant mothers. 4. The use of proper posture and good body mechanics throughout pregnancy is important. 5. Good posture is important because it allows more room for the stomach to function.

The nurse is holding a class for newly pregnant couples, and discussing good and bad influences on their developing babies. Prenatal influences on the intrauterine environment include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The use of saunas or hot tubs 2. The use of drugs 3. The quality of the sperm or ovum 4. Maternal nutrition 5. Vitamins and folic acid

Answer: 1, 2, 4, 5 Explanation: 1. The use of saunas or hot tubs is associated with maternal hyperthermia. Studies of the effects of maternal hyperthermia during the first trimester have raised concern about possible spontaneous abortion, central nervous system (CNS) defects, and failure of neural tube closure. 2. The use of drugs can have teratogenic effects. 4. Maternal nutrition affects brain and neural tube development. 5. Vitamins and folic acid supplements taken before conception can reduce the incidence of neural tube defects.

The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.

Answer: 1, 2, 4, 5 Explanation: 1. With the fiber-optic blanket, the light stays on at all times. 2. The eyes do not have to be covered with a fiber optic blanket. 4. With the fiber-optic blanket, greater surface area is exposed and there are no thermoregulation issues. 5. Fluid and weight loss are not complications of fiber-optic blankets.

When caring for a 13-year-old client in labor, how would the nurse provide sensitive care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Using simple and concrete instructions 2. Providing soothing encouragement and comfort measures 3. Making all decisions for the client when she expresses a feeling of helplessness 4. Deciding whom the client should allow in the room 5. Providing encouragement and support of the client's decisions

Answer: 1, 2, 5 Explanation: 1. A client at this developmental stage will need concrete and simplified instructions. 2. Touch, soothing encouragement, and measures to promote her comfort help her maintain control and meet her needs for dependence. 5. Establishing rapport without recrimination will provide emotional support and encouragement.

) The client and her partner are carriers of sickle-cell disease. They are considering prenatal diagnosis with either amniocentesis or chorionic villus sampling (CVS). Which statements indicate that further teaching is needed on these two diagnostic procedures? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Chorionic villus sampling carries a lower risk of miscarriage." 2. "Amniocentesis can be done earlier in my pregnancy than CVS." 3. "Neither test will conclusively diagnose sickle-cell disease in our baby." 4. "The diagnosis comes sooner if we have CVS, not amniocentesis." 5. "Amniocentesis is more accurate in diagnosis than the CVS."

Answer: 1, 2, 5 Explanation: 1. CVS has a risk of spontaneous abortion of 0.3% in cases. This rate is higher than second trimester amniocentesis. 2. CVS is performed in some medical centers for first trimester diagnosis after 9 completed weeks. Amniocentesis is performed between 15 and 20 weeks' gestation. 5. Much like amniocentesis, chorionic villus sampling (CVS) is a procedure that is used to detect genetic, metabolic, and DNA abnormalities. CVS permits earlier diagnosis than can be obtained by amniocentesis.

Risk factors associated with increased risk of thromboembolic disease include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Diabetes mellitus 2. Varicose veins 3. Hypertension 4. Adolescent pregnancy 5. Malignancy

Answer: 1, 2, 5 Explanation: 1. Diabetes mellitus is a risk factor for thromboembolic disease. 2. Varicose veins are a risk factor for thromboembolic disease. 5. Malignancy is a risk factor for thromboembolic disease.

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal heart rate of 130 with average variability 2. Blood pressure of 130/80 3. Maternal pulse of 160 4. Protein of +1 in urine 5. Odorless, clear fluid on underwear

Answer: 1, 2, 5 Explanation: 1. Fetal heart rate (FHR) of 110-160 with average variability is a normal indication. 2. Maternal vital sign of blood pressure below 140/90 is a normal indication. 5. Fluid clear and without odor if membranes ruptured is a normal indication.

The 22-year-old client is scheduled for her first gynecologic examination. What can the nurse do to make the client more comfortable during this exam? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Create a trusting atmosphere. 2. Show the client what the speculum looks like. 3. Avoid telling the client what the exam involves. 4. Ask the client why she has delayed her first Pap test this long. 5. Provide a mirror for the client.

Answer: 1, 2, 5 Explanation: 1. It is important to create a trusting atmosphere and incorporate practices that help the client maintain a sense of control. 2. Show the client all of the equipment to be used. 5. Provide a mirror to increase learning about anatomy and to create a trusting atmosphere.

Which of the following are potential disadvantages to breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pain with breastfeeding 2. Leaking milk 3. Equal feeding responsibilities with fathers 4. Vaginal wetness 5. Embarrassment

Answer: 1, 2, 5 Explanation: 1. Nipple tenderness is the most common source of discomfort and is usually related to improper positioning and/or not obtaining a proper attachment of the infant on the breast. Pain can also be related to engorgement or infection. 2. Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience let-down. Mothers should be given reassurance that this problem diminishes over time. 5. Some mothers feel uncomfortable about breastfeeding because they are modest or may feel embarrassed because our society views breasts as sexual objects and/or an unfriendly social environment makes it difficult to breastfeed in public. This is not an easy issue to overcome.

Ovarian hormones include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Estrogens 2. Progesterone 3. Parathyroid hormone 4. Luteinizing hormone 5. Testosterone

Answer: 1, 2, 5 Explanation: 1. Ovarian hormones include the estrogens, progesterone, and testosterone. 2. Ovarian hormones include the estrogens, progesterone, and testosterone. 5. Ovarian hormones include the estrogens, progesterone, and testosterone.

A new mother is questioning the nurse about the advantages of breastfeeding her newborn. Which information should the nurse include in the teaching session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Breast milk has immunological advantages, including varying degrees of protection from bacterial and viral infections. 2. Breastfeeding has been shown to increase maternal-infant attachment. 3. Breastfeeding can be initially supplemented with bottle feedings so that the father does not feel left out of the infant's care. 4. Breastfeeding often causes nipple tenderness, and may be discouraged until healing occurs. 5. Breastfeeding provides a psychologic advantage to the mother, who derives satisfaction knowing that she is providing her infant with the optimal nutritional start in life.

Answer: 1, 2, 5 Explanation: 1. Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties. 2. Early breastfeeding can enhance maternal-infant bonding. 5. The mother's sense of accomplishment in being able to satisfy her baby's needs for nourishment and comfort can be a tremendous source of personal satisfaction.

Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Breastfed infants get more skin-to-skin contact and sleep better." 2. "Breastfeeding raises the level of a hormone that makes me feel good." 3. "Breastfeeding is complex and difficult, and I probably won't succeed." 4. "Breastfeeding is worthwhile, even if it costs more overall." 5. "Breastfed infants have fewer digestive and respiratory illnesses."

Answer: 1, 2, 5 Explanation: 1. Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding. 2. Hormones of lactation promote maternal feelings and sense of well-being. 5. This is a true statement. The immunologic advantages of human milk include varying degrees of protection from respiratory tract and gastrointestinal tract infections.

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the baby's ability to focus.

Answer: 1, 2, 5 Explanation: 1. Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. 2. After administration, the nurse massages the eyelid gently to distribute the ointment. 5. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces.

3) A client in labor is requesting pain medication. The nurse assesses her labor status first, focusing on which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Contraction pattern 2. Amount of cervical dilatation 3. When the labor began 4. Whether the membranes are intact or ruptured 5. Fetal presenting part

Answer: 1, 2, 5 Explanation: 1. The client should have a good contraction pattern before receiving an analgesic. 2. The nurse should evaluate the amount of cervical dilatation before analgesic medication is administered. 5. If normal parameters are absent or if nonreassuring maternal or fetal factors are present, the nurse may need to complete further assessments with the physician/CNM.

Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the client's room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the client's room. 5. Teach using one-to-one instruction while in the client's room.

Answer: 1, 2, 5 Explanation: 1. The nurse can be an excellent role model for families. Teaching by example is a very effective way to teach infant care. 2. One-to-one teaching while the nurse is in the client's room is shown to be the most effective educational model. 5. One-to-one teaching while the nurse is in the client's room is the most effective educational model.

To maintain a healthy temperature in the newborn, which of the following actions should be taken? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Keep the newborn's clothing and bedding dry. 2. Reduce the newborn's exposure to drafts. 3. Do not use the radiant warmer during procedures. 4. Do not wrap the newborn. 5. Encourage the mother to snuggle with the newborn under blankets.

Answer: 1, 2, 5 Explanation: 1. To maintain a healthy temperature in the newborn, keep the newborn's clothing and bedding dry. 2. To maintain a healthy temperature in the newborn, reduce the newborn's exposure to drafts. 5. To maintain a healthy temperature in the newborn, encourage the mother to snuggle with the newborn under blankets.

During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Intravenous access 2. Cesarean delivery 3. Immediate vaginal delivery 4. McRoberts maneuver 5. A crash cart

Answer: 1, 2, 5 Explanation: 1. When an amniotic fluid embolism is suspected, intravenous access is obtained as quickly as possible. 2. Shortness of breath, cyanosis, and hypoxia are symptoms of an amniotic fluid embolus, which necessitates immediate cesarean delivery. 5. The chances of a code are high, so the crash cart needs to be available.

During the history, the client admits to being HIV-positive and says she knows that she is about 16 weeks pregnant. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "During labor and delivery, I can expect the zidovudine (ZDV) to be given in my IV." 2. "After delivery, the dose of zidovudine (ZDV) will be doubled to prevent further infection." 3. "My baby will be started on zidovudine (ZDV) for six weeks following the birth." 4. "My baby's zidovudine (ZDV) will be given in a cream form." 5. "My baby will not need zidovudine (ZDV) if I take it during my pregnancy."

Answer: 1, 3 Explanation: 1. ART therapy generally it includes oral Zidovudine (ZDV) daily, IV ZDV during labor and until birth, and ZDV therapy for the infant for 6 weeks following birth. 3. ART therapy generally it includes oral Zidovudine (ZDV) daily, IV ZDV during labor and until birth, and ZDV therapy for the infant for 6 weeks following birth.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is stable, and labor is progressing. Which parts of the nurse's assessment have the highest priority? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess blood pressure every hour. 2. Assess the pulse rate every hour. 3. Palpate the bladder. 4. Auscultate the lungs. 5. Assess the reflexes.

Answer: 1, 3 Explanation: 1. Blood pressure should be monitored every 1 to 2 minutes for the first 10 minutes and then every 5 to 15 minutes until the block wears off because hypotension is the most common side effect of epidural anesthesia. 3. Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention. Catheterization may be necessary, because most women are unable to void.

A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Methergine 2. Coumadin 3. Misoprostol 4. Serotonin reuptake inhibitors (SSRIs) 5. Nonsteroidal anti-inflammatory drugs

Answer: 1, 3 Explanation: 1. Methergine is commonly used orally for postpartum hemorrhage. 3. Misoprostol is commonly used rectally for postpartum hemorrhage.

The client at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the client understands the treatment being administered? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "The baby needs to be monitored to check the heart rate." 2. "My bowel has probably been lacerated by the knife." 3. "I might need an ultrasound to look at the baby." 4. "The catheter in my bladder will prevent urinary complications." 5. "The IV in my arm will replace the amniotic fluid if it is leaking."

Answer: 1, 3 Explanation: 1. Ongoing assessments of trauma include evaluation of uterine tone, contractions and tenderness, fundal height, fetal heart rate, intake and output and other indicators of shock, normal postoperative evaluation in those women requiring surgery, determination of neurologic status, and assessment of mental outlook and anxiety level. 3. In cases of noncatastrophic trauma, where the mother's life is not directly threatened, fetal monitoring for 4 hours should be sufficient if there is no vaginal bleeding, uterine tenderness, contractions, or leaking amniotic fluid.

The nurse is at the home of a postpartum client for an initial assessment. The client gave birth by cesarean section 1 week earlier. Which statements should the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Because you had a cesarean, I'd like to assess your incision." 2. "You aren't having any problems nursing, right?" 3. "How rested do you feel since you came home?" 4. "Because you are bottle-feeding, I won't assess your breasts." 5. "You should remain at home for the first 3 weeks after delivery."

Answer: 1, 3 Explanation: 1. The nurse should assess the cesarean incision. 3. The nurse should talk with the mother about her fatigue level and ability to rest and sleep. Page Ref: 929, 931

What are the primary complications of placenta accrete? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal hemorrhage 2. Insomnia 3. Failure of the placenta to separate following birth of the infant 4. Autonomic dysreflexia 5. Shoulder dystocia

Answer: 1, 3 Explanation: 1. The primary complications of placenta accreta are maternal hemorrhage and failure of the placenta to separate following birth of the infant. 3. The primary complications of placenta accreta are maternal hemorrhage and failure of the placenta to separate following birth of the infant.

The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Early feedings stimulate peristalsis. 2. Colostrum is thinner than mature milk. 3. Early feedings enhance maternal-infant bonding. 4. Early feedings promote the passage of meconium. 5. Colostrum contains a high number of calories.

Answer: 1, 3, 4 Explanation: 1. Early breastfeeding stimulates the newborn's peristalsis. 3. Early breastfeeding enhances maternal-infant bonding. 4. Early breastfeeding promotes the passage of meconium.

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Newborns have less subcutaneous fat than do adults. 2. Infants have a thick epidermis layer. 3. Newborns have a large body surface to weight ratio. 4. Infants have increased total body water. 5. Newborns have more subcutaneous fat than do adults.

Answer: 1, 3, 4 Explanation: 1. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's decreased subcutaneous fat. 3. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's large body surface to weight ratio. 4. Preterm infants have increased heat loss via evaporation due to increased total body water.

The nurse is assessing a client in the third trimester of pregnancy. What physiologic changes in the client are expected? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The client's chest circumference has increased by 6 cm during the pregnancy. 2. The client has a narrowed subcostal angle. 3. The client is using thoracic breathing. 4. The client may have epistaxis. 5. The client has a productive cough.

Answer: 1, 3, 4 Explanation: 1. The chest increase compensates for the elevated diaphragm. 3. Breathing changes from abdominal to thoracic as pregnancy progresses. 4. Epistaxis (nosebleeds) may occur and are primarily the result of estrogen-induced edema and vascular congestion of the nasal mucosa.

The nurse in the OB-GYN clinic counsels a couple that in autosomal dominant inheritance, which of the following occur? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. An affected individual might have an affected parent. 2. The affected individual has a 75% chance of passing on the abnormality. 3. Males and females are equally affected by the gene. 4. A father can pass the defective gene to a son. 5. There are no variances in the genetic pattern for autosomal dominant disorders.

Answer: 1, 3, 4 Explanation: 1. The family pedigree usually shows multiple generations having the disorder. 3. Males and females are equally affected in autosomal dominant disorders. 4. In autosomal dominant disorders, the father can pass the defective gene to a son.

The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight

Answer: 1, 3, 4 Explanation: 1. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing vital signs (body temperature, heart rate, respiratory rate). 3. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing airway clearance. 4. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing ability to feed.

The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally.

Answer: 1, 3, 4 Explanation: 1. The nurse should instruct the parents on proper hand-washing technique. 3. The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed, and disposed of daily. 4. The nurse should instruct parents that the diaper-changing areas should be cleaned with a 1:10 dilution of household bleach after each diaper change.

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle.

Answer: 1, 3, 4 Explanation: 1. The nurse would remove the needle and massage the site with an alcohol swab. 3. Vitamin K is given intramuscularly in the vastus lateralis muscle. 4. Before injecting, the nurse must clean the newborn's skin site for the injection thoroughly with a small alcohol swab.

The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure.

Answer: 1, 3, 4, 5 Explanation: 1. 0.5 to 1 mg is the correct dosage for vitamin K. 3. 25-gauge, 5/8-inch needle is the right size needle to use. 4. Vitamin K must be kept away from light. 5. A prophylactic injection of vitamin K1 is given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.

Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cyanosis 2. Heart murmur 3. Bradycardia 4. Low urinary outputs 5. Tachypnea

Answer: 1, 3, 4, 5 Explanation: 1. Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect. 3. The signs of congestive heart failure include tachycardia, not bradycardia. 4. The signs of congestive heart failure include low urinary output. 5. The signs of congestive heart failure include tachypnea.

) The nurse is caring for a prenatal client. Reviewing the client's pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The mother's low socioeconomic status 2. Maternal age of 26 3. Mother's exposure to toxic chemicals 4. More than three previous deliveries 5. Maternal hypertension

Answer: 1, 3, 4, 5 Explanation: 1. Low socioeconomic status is associated with at-risk newborns. 3. Exposure to environmental dangers, such as toxic chemicals is associated with at-risk newborns. 4. Maternal factors such as multiparity are associated with at-risk newborns. 5. Preexisting maternal conditions, such as heart disease, diabetes, hypertension, hyperthyroidism, and renal disease are associated with at-risk newborns.

The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. More than one episode of forceful vomiting. 2. More than 6 to 10 wet diapers per day. 3. A bluish discoloration of the skin with or without a feeding. 4. Refusal of two feedings in a row. 5. Development of eye drainage.

Answer: 1, 3, 4, 5 Explanation: 1. More than one episode of forceful vomiting or frequent vomiting over a 6-hour period should be reported to the healthcare provider. 3. Cyanosis (bluish discoloration of skin) with or without a feeding is a cause for concern, and should be reported to the healthcare provider immediately. 4. Refusal of two feedings in a row should be reported to the healthcare provider. 5. The infant should not have eye drainage after discharge and this condition should be reported to the healthcare provider.

Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding

Answer: 1, 3, 4, 5 Explanation: 1. Nonreassuring fetal heart rate pattern/sustained bradycardia would be considered a potential need to resuscitate a newborn. 3. History of meconium in amniotic fluid would be considered a potential need to resuscitate a newborn. 4. Prematurity would be considered a potential need to resuscitate a newborn. 5. Significant intrapartum bleeding would be considered a potential need to resuscitate a newborn.

The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Continual rise in temperature 2. Decreased frequency of stools 3. Absence of breathing longer than 20 seconds 4. Lethargy 5. Refusal of two feedings in a row

Answer: 1, 3, 4, 5 Explanation: 1. Parents should call their healthcare provider due to a continual rise in temperature. 3. Parents should call their healthcare provider in the absence of breathing longer than 20 seconds. 4. Parents should call their healthcare provider if the newborn exhibits lethargy and listlessness. 5. Parents should call their healthcare provider if the newborn has refused of two feedings in a row.

When general anesthesia is necessary for a cesarean delivery, what should the nurse be prepared to do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer an antacid to the client. 2. Place a wedge under her thigh. 3. Apply cricoid pressure during anesthesia intubation. 4. Preoxygenate for 3-5 minutes before anesthesia. 5. Place a Foley catheter in the client's bladder.

Answer: 1, 3, 4, 5 Explanation: 1. Prophylactic antacid therapy is given to reduce the acidic content of the stomach before general anesthesia. 3. During the process of rapid induction of anesthesia, the nurse applies cricoid pressure. 4. The woman should be preoxygenated with 3 to 5 minutes of 100% oxygen. 5. Urinary retention can be treated with the placement of an indwelling Foley catheter.

A new mother inquires about postpartum resources. What resources can the nurse suggest to provide assistance to the new mother? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Breastfeeding support groups 2. Meals on Wheels 3. Lactation consultants 4. Postpartum classes 5. Internet sites

Answer: 1, 3, 4, 5 Explanation: 1. Support groups provide an opportunity for parents to interact with one another and share information. 3. Lactation consultants are helpful for women who are having breastfeeding problems or concerns. 4. Postpartum classes offer chances for the new mother to socialize, share concerns, and receive encouragement. 5. The nurse's role is to direct the new mother to reliable web sites.

Usually, the family is advised to arrive at the birth setting at the beginning of the active phase of labor or when which of the following occur? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Rupture of membranes (ROM) 2. Increased fetal movement 3. Decreased fetal movement 4. Any vaginal bleeding 5. Regular, frequent uterine contractions (UCs)

Answer: 1, 3, 4, 5 Explanation: 1. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when the membranes rupture. 3. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there is decreased fetal movement. 4. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there is any vaginal bleeding. 5. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there are regular, frequent uterine contractions.

A nurse is performing a postpartum assessment during the first home visit to a client 3 days postdelivery. Which actions will the nurse perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

Answer: 1, 3, 4, 5 Explanation: 1. The nurse needs to assess for fullness and engorgement. 3. The nurse should check vaginal discharge for amount and color. 4. The extremities should be checked for any redness, edema, and tenderness. 5. The perineum needs to be checked for healing.

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.

Answer: 1, 3, 4, 5 Explanation: 1. The nurse will assist in obtaining skin cultures. Skin cultures are taken of any lesions or drainage from lesions or reddened areas. 3. The nurse will observe for hyperbilirubinemia, anemia, and hemorrhagic symptoms. 4. The nurse will administer oxygen as ordered. 5. The nurse will observe for signs of hypoglycemia.

When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hypoxia 2. Respiratory alkalosis 3. Metabolic acidosis 4. Massive atelectasis 5. Pulmonary edema

Answer: 1, 3, 4, 5 Explanation: 1. The physiologic alterations of RDS can produce hypoxia as a complication. As a result of hypoxia, the pulmonary vasculature constricts, pulmonary vascular resistance increases, and pulmonary blood flow is reduced. 3. The physiologic alterations of RDS can produce metabolic acidosis as a complication. Because cells lack oxygen, the newborn begins an anaerobic pathway of metabolism, with an increase in lactate levels and a resulting base deficit. 4. The physiologic alterations of RDS can produce massive atelectasis as a complication. Upon expiration, the instability increases the atelectasis, which causes hypoxia and acidosis because of the lack of gas exchange. 5. The physiologic alterations of RDS can produce pulmonary edema as a complication. Opacification of the lungs on X-ray image may be due to massive atelectasis, diffuse alveolar infiltrate, or pulmonary edema.

The nurse understands that a client's pregnancy is progressing normally when what physiologic changes are documented on the prenatal record of a woman at 36 weeks' gestation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The joints of the pelvis have relaxed, causing a waddling gait. 2. The cervix is firm and blue-purple in color. 3. The uterus vasculature contains one sixth of the total maternal blood volume. 4. Gastric emptying time is delayed, and the client complains of constipation and bloating. 5. Supine hypotension occurs when the client lies on her back.

Answer: 1, 3, 4, 5 Explanation: 1. The sacroiliac, sacrococcygeal, and pubic joints of the pelvis relax in the later part of the pregnancy, presumably as a result of hormonal changes. This often causes a waddling gait. 3. By the end of pregnancy, one sixth of the total maternal blood volume is contained within the vascular system of the uterus. 4. Gastric emptying time and intestinal motility are delayed, leading to frequent complaints of bloating and constipation, which can be aggravated by the smooth muscle relaxation and increased electrolyte and water reabsorption in the large intestine. 5. The enlarging uterus may exert pressure on the vena cava when the woman lies supine, causing a drop in blood pressure. This is called the vena caval syndrome, or supine hypotension.

The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Note: Credit will be given if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tremors 2. Hyperglycemia 3. Hyperbilirubinemia 4. Respiratory distress syndrome 5. Birth trauma

Answer: 1, 3, 4, 5 Explanation: 1. Tremors are a clinical sign of hypocalcemia. 3. Hyperbilirubinemia is caused by slightly decreased extracellular fluid volume, which increases the hematocrit level. 4. Respiratory distress syndrome (RDS) is a complication that occurs more frequently in newborns of diabetic mothers whose diabetes is not well controlled. 5. Because most IDMs are macrosomic, trauma may occur during labor and vaginal birth resulting in shoulder dystocia, brachial plexus injuries, subdural hemorrhage, cephalohematoma, and asphyxia.

A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of labor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Knowledge, Deficient, related to lack of information about pushing methods 3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 4. Pain, Acute, related to perineal trauma 5. Coping: Family, Compromised, related to labor process

Answer: 1, 3, 5 Explanation: 1. A Fear/Anxiety diagnosis would apply to the first stage of labor for a first-time labor client. 3. Contractions become more regular in frequency and duration, increasing discomfort and pain. 5. The woman and her boyfriend are about to undergo one of the most meaningful and stressful events in life together. Physical and psychologic resources, coping mechanisms, and support systems will all be challenged.

Clinical features of posttraumatic stress disorder (PTSD) include which of the following? 1. Difficulty sleeping 2. Acute awareness 3. Flashbacks 4. The need to be constantly around others 5. Irritability

Answer: 1, 3, 5 Explanation: 1. A clinical feature of PTSD is difficulty thinking. 3. A clinical feature of PTSD is intrusive thoughts and flashbacks to the threatening event. 5. A clinical feature of PTSD is irritability.

The nurse working in a women's clinic recognizes that which clients are most at risk for developing vulvovaginal candidiasis? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Clients using antibiotics 2. Immunocompetent clients 3. Pregnant clients 4. Multiparous clients 5. Diabetic clients

Answer: 1, 3, 5 Explanation: 1. A predisposing factor to yeast infections includes the use of antibiotics. 3. Predisposing factors to yeast infections include pregnancy. 5. Predisposing factors to yeast infections include glycosuria and diabetes mellitus.

The OB-GYN nurse teaches a first-time pregnant client that functions of the amniotic fluid include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Allowing fetal freedom of movement 2. Releasing heat to control fetal temperature 3. Acting as an extension of fetal extracellular space 4. Providing a water source for the fetus to swallow 5. Acting as a wedge during labor

Answer: 1, 3, 5 Explanation: 1. Amniotic fluid permits fetal freedom of movement. 3. A primary function of amniotic fluid is to act as an extension of fetal extracellular space. 5. A primary function of amniotic fluid is to act as a wedge during labor.

Student nurses in their obstetrical rotation are learning about fertilization and implantation. The process of implantation is characterized by which statements? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The trophoblast attaches itself to the surface of the endometrium. 2. The most frequent site of attachment is the lower part of the anterior uterine wall. 3. Between days 7 and 10 after fertilization, the zona pellucida disappears, and the blastocyst implants itself by burrowing into the uterine lining. 4. The lining of the uterus thins below the implanted blastocyst. 5. The cells of the trophoblast grow down into the uterine lining, forming the chorionic villi.

Answer: 1, 3, 5 Explanation: 1. During implantation, the trophoblast attaches itself to the surface of the endometrium for further nourishment. 3. Between days 7 and 10 after fertilization, the zona pellucida disappears, and the blastocyst implants itself by burrowing into the uterine lining and penetrating down toward the maternal capillaries until it is completely covered. 5. The cells of the trophoblast grow down into the thickened lining, forming the chorionic villi.

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Low pitched cry 5. Transient tachypnea

Answer: 1, 3, 5 Explanation: 1. Newborns born to drug-addicted mothers exhibit hyperirritability. 3. Newborns born to drug-addicted mothers exhibit exaggerated reflexes. 5. Newborns born to drug-addicted mothers exhibit transient tachypnea.

A client at 34 weeks' gestation complains about pyrosis. The nurse teaches the patient that approaches to relieve the pyrosis include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Eat small, frequent meals 2. Use high-sodium antacids 3. Avoid fried, fatty foods 4. Take sodium bicarbonate after meals 5. Do not lie down after eating

Answer: 1, 3, 5 Explanation: 1. Pyrosis (heartburn) can be relieved by eating small, more frequent meals. 3. Avoiding fatty, fried foods can relieve pyrosis. 5. Sitting up after meals will help decrease the pyrosis.

The nurse is teaching a group of adolescents that sperm must undergo the process of capacitation in order to fertilize the ova. The characteristics of sperm that have undergone capacitation include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ability to undergo an acrosomal reaction 2. Ability to block polyspermy 3. Ability to bind to the zona pellucida 4. Ability to release norepinephrine 5. Acquisition of hypermotility

Answer: 1, 3, 5 Explanation: 1. Sperm that undergo capacitation take on the ability to undergo the acrosomal reaction. 3. Sperm that undergo capacitation take on the ability to bind to the zona pellucida. 5. Sperm that undergo capacitation have the acquisition of hypermotility.

The nurse recognizes the importance of the interaction between the nervous and endocrine systems in the female reproductive cycle. The interaction involves which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Hypothalamus 2. Adrenal cortex 3. Ovaries 4. Thyroid 5. Anterior pituitary

Answer: 1, 3, 5 Explanation: 1. The female reproductive cycle is controlled by complex interactions between the nervous and endocrine systems and their target tissues. These interactions involve the hypothalamus. 3. The female reproductive cycle is controlled by complex interactions between the nervous and endocrine systems and their target tissues. These interactions involve the ovaries. 5. The female reproductive cycle is controlled by complex interactions between the nervous and endocrine systems and their target tissues. These interactions involve the anterior pituitary.

The clinic nurse is assessing how the prenatal client is meeting developmental tasks using Rubin's tasks, including which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ensuring safe passage through pregnancy, labor, and birth. 2. Turning in on oneself to focus on the child. 3. Seeking commitment and acceptance of self as mother to the infant. 4. Completing the tasks of nesting at the appropriate time. 5. Seeking acceptance of the child by others.

Answer: 1, 3, 5 Explanation: 1. The tasks Rubin identified form the basis for a mutually gratifying relationship with the baby, and include ensuring safe passage through pregnancy, labor, and birth. 3. The tasks Rubin identified form the basis for a mutually gratifying relationship with the baby, and include seeking commitment and acceptance of self as mother. 5. The tasks Rubin identified form the basis for a mutually gratifying relationship with the baby, and include seeking acceptance of the child by others.

A client at 18 weeks' gestation has been diagnosed with a hydatidiform mole. In addition to vaginal bleeding, which signs or symptoms would the nurse expect to see? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperemesis gravidarum 2. Diarrhea and hyperthermia 3. Uterine enlargement greater than expected 4. Polydipsia 5. Vaginal bleeding

Answer: 1, 3, 5 Explanation: 1. This is often seen in clients with hydatidiform mole. 3. This is a classic sign of hydatidiform mole. 5. This is a classic symptom of hydatidiform mole.

A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Android 2. Anthropoid 3. Gynecoid 4. Platypelloid 5. Lambdoidal suture

Answer: 1, 4 Explanation: 1. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. 4. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely.

The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor most likely will include which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions are at regular intervals

Answer: 1, 4 Explanation: 1. True labor contractions intensify while walking. 4. The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen.

) The nurse is caring for a postpartum client who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina. 2. Massage the uterus every 2 hours. 3. Maintain vascular access. 4. Obtain blood specimens for hemoglobin and hematocrit. 5. Encourage the client to void if the fundus is displaced upward or to one side.

Answer: 1, 4 Explanation: 1. Weighing the perineal pads will indicate whether the client is bleeding more than anticipated. 4. The nurse reviews hemoglobin and hematocrit levels when available, and compares them to the admission baseline.

A school nurse teaching a health class to adolescent boys explains that spermatozoa become motile and fertile during the 2-10 days they are stored in which part of the male body? 1. Prostate gland 2. Vas deferens 3. Epididymis 4. Urethra

Answer: 3 Explanation: 3. The epididymis provides a reservoir where spermatozoa can survive for a long period and the spermatozoa usually remain in the epididymis for 2 to 10 days.

To answer a client's question about home pregnancy tests and their accuracy, the nurse must know that accuracy is affected by which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Unclear directions 2. Unable to comprehend the directions 3. Blood in the specimen giving a false reading 4. Completing the test too late 5. Tagged antibodies becoming outdated

Answer: 1, 4 Explanation: 1. Women may not comprehend the HPT instructions, which can affect the accuracy results. 4. False-negative results typically occur when the test is completed too early or too late.

The nurse is assessing a client who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A boggy fundus that does not respond to massage 2. Small clots and a moderate amount of lochia rubra on the pad 3. Decreased pulse and increased blood pressure 4. Hematoma formation or bulging/shiny skin in the perineal area 5. Rise in the level of the fundus of the uterus

Answer: 1, 4, 5 Explanation: 1. A boggy fundus indicates that the uterus is not contracted and will continue to bleed. 4. Shiny or bulging skin could indicate the presence of a hematoma. 5. The uterine cavity can distend with up to 1000 mL or more of blood causing the fundus to rise.

The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Offer a warm water bottle for her abdomen. 2. Call the physician to report this finding. 3. Inform her that this is not normal, and she will need an oxytocic agent. 4. Administer a mild analgesic to help with breastfeeding. 5. Administer a mild analgesic at bedtime to ensure rest.

Answer: 1, 4, 5 Explanation: 1. A warm water bottle placed against the low abdomen may reduce the discomfort of afterpains. 4. The breastfeeding mother may find it helpful to take a mild analgesic agent approximately 1 hour before feeding her infant. 5. An analgesic agent such as ibuprofen is also helpful at bedtime if the afterpains interfere with the mother's rest.

Which factors would the nurse observe that would indicate a new mother's early attachment to the newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Face-to-face contact and eye contact 2. Failure to choose a name for the baby 3. Decreased interest in the infant's cues 4. Pointing out familial traits of the newborn 5. Displaying satisfaction with the infant's sex

Answer: 1, 4, 5 Explanation: 1. Face-to-face contact and eye contact indicates that the mother is attracted to the infant and is attending to the infant's behavior. 4. The ability to point out family traits shows that she is pleased with the baby's appearance and recognizes the infant as belonging to the family unit. 5. Showing pleasure with the infant's appearance and sex indicates bonding is occurring.

The nurse knows that the Bishop scoring system for cervical readiness includes which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal station 2. Fetal lie 3. Fetal presenting part 4. Cervical effacement 5. Cervical softness

Answer: 1, 4, 5 Explanation: 1. Fetal station is one of the components evaluated by the Bishop scoring system. 4. Cervical effacement is one of the components evaluated by the Bishop scoring system. 5. Cervical consistency is one of the components evaluated by the Bishop scoring system.

The clinic nurse assesses a newborn that is not progressing as expected. Genetic tests are ordered. The nurse explains to the parents that the laboratory tests to be done include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Chromosome analysis 2. Complete blood count 3. Phenylketonuria 4. Enzyme assay 5. Antibody titers

Answer: 1, 4, 5 Explanation: 1. Laboratory analysis includes chromosome analysis. 4. Laboratory analysis includes enzyme assay for inborn errors of metabolism. 5. Laboratory analysis includes antibody titers for infectious teratogens.

The nurse is planning a group session for clients who are beginning infertility evaluation. Which statements should be included in this session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Infertility can be stressful for a marriage." 2. "The doctor will be able to tell why you have not conceived." 3. "Your insurance will pay for the infertility treatments." 4. "Keep communicating with one another through this process." 5. "Support organizations can be helpful to deal with the emotional issues associated with infertility."

Answer: 1, 4, 5 Explanation: 1. Often an intact marriage will become stressed by the intrusive but necessary infertility procedures and treatments. 4. Communication is important; clients should communicate verbally and share feelings and support. 5. Referral to mental health professionals is helpful when the emotional issues become too disruptive in the couple's relationship or life. Couples should be made aware of infertility support and education organizations, which may help meet some of these needs and validate their feelings.

Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Swollen glands 2. Hard stools 3. Smaller than average spleen and liver 4. Rhinorrhea 5. Interstitial pneumonia

Answer: 1, 4, 5 Explanation: 1. Signs that may be seen in the early infancy period include swollen glands. 4. Signs that may be seen in the early infancy period include rhinorrhea. 5. Signs that may be seen in the early infancy period include interstitial pneumonia.

A client is admitted to the labor suite. It is essential that the nurse assess the woman's status in relation to which infectious diseases? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Chlamydia trachomatis 2. Rubeola 3. Varicella 4. Group B streptococcus 5. Acute pyelonephritis

Answer: 1, 4, 5 Explanation: 1. The infant may develop chlamydial pneumonia and Chlamydia trachomatis may be responsible for premature labor and fetal death. Chlamydial infection should be assessed. 4. Women may transmit GBS to their fetus in utero or during childbirth. GBS is a leading infectious cause of neonatal sepsis and mortality and should be assessed. 5. Acute pyelonephritis should be assessed as there is an increased risk of premature birth and intrauterine growth restriction (IUGR).

A client who is having false labor most likely would have which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions that lessen with rest and warm tub baths

Answer: 1, 4, 5 Explanation: 1. True labor contractions intensify while walking. 4. True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. 5. In true labor, contractions do not lessen with rest and warm tub baths.

The nurse explains the functions of the male reproductive organs to a client. Which correct functions will the nurse include? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Ejaculatory ducts move semen and seminal fluid. 2. The adrenal gland is the major source of testosterone. 3. The vas deferens ends before reaching the prostate gland. 4. Sertoli's cells nourish spermatozoa. 5. The testes house seminiferous tubules.

Answer: 1, 5 Explanation: 1. Ejaculatory ducts provide a passageway for semen and seminal fluid into the urethra. 5. The testes house seminiferous tubules and the gonads.

Methods to increase fertility awareness include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Home assessment of cervical mucus 2. Pharmacologic agents 3. Therapeutic insemination 4. IVF 5. Basal body temperature (BBT) recordings

Answer: 1, 5 Explanation: 1. Methods to increase fertility awareness include home assessment of cervical mucus and basal body temperature (BBT) recordings. 5. Methods to increase fertility awareness include home assessment of cervical mucus and basal body temperature (BBT) recordings.

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy increases serum bilirubin levels. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage.

Answer: 1, 5 Explanation: 1. Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. 5. Kernicterus refers to the deposition of unconjugated bilirubin in the basal ganglia of the brain and to permanent neurologic sequelae of untreated hyperbilirubinemia.

A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infant's head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someone's arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infant's nostrils as necessary

Answer: 1, 5 Explanation: 1. The newborn should be placed on his or her back (supine) for sleeping. 5. During the first few days of life, the newborn has increased mucus, and gentle suctioning with a bulb syringe may be indicated.

The nurse is reviewing amniocentesis results. Which of the following would indicate that client care was appropriate? 1. The client who is Rh-positive received Rh immune globulin after the amniocentesis. 2. The client was monitored for 30 minutes after completion of the test. 3. The client began vaginal spotting before leaving for home after the test. 4. The client identified that she takes insulin before each meal and at bedtime.

Answer: 2 Explanation: 2. 20 to 30 minutes of fetal monitoring is performed after the amniocentesis.

A nurse is teaching a class on the different types of uterine bleeding. The nurse explains that which of the following is one of the causes of abnormal uterine bleeding? 1. Iron-deficiency anemia 2. Polyps 3. Heavy periods every 2 months 4. Spotting between periods

Answer: 2 Explanation: 2. A classification system has been developed for the causes of AUB using the acronym PALM-COEIN. The P stands for Polyps.

A client at 37 weeks' gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates three contractions in 10 minutes, no decelerations, and accelerations four times in 1 hour. What would this test be considered? 1. Positive non-stress test 2. Negative contraction stress test 3. Positive contraction stress test 4. Negative non-stress test

Answer: 2 Explanation: 2. A negative CST shows three contractions of good quality lasting 40 or more seconds in 10 minutes without evidence of late decelerations. This is the desired result.

A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? 1. Decreased bladder capacity 2. Inhibited neural control of the bladder following the use of anesthetic agents 3. Increased bladder sensitivity 4. Abnormal postpartum diuresis

Answer: 2 Explanation: 2. A postpartum woman is at increased risk for developing urinary tract problems because of inhibited neural control of the bladder following the use of anesthetic agents.

The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? 1. "If I had taken better care of myself, this wouldn't have happened." 2. "I've been sleeping very well since I had the baby." 3. "This is probably the doctor's fault." 4. "If I hadn't seen our baby's birth, I wouldn't believe she is ours."

Answer: 2 Explanation: 2. A sick infant is a source of great anxiety for parents. This response is from the mother would be unexpected.

Which of the following tests provides information about the fetal number? 1. Amniocentesis 2. Standard second-trimester sonogram 3. Beta hCG 4. Maternal serum alpha-fetoprotein

Answer: 2 Explanation: 2. A standard (comprehensive) second trimester sonogram provides the information about the fetus, placenta, and uterine conditions including fetal number.

Women with HIV should be evaluated and treated for other sexually transmitted infections and for what condition occurring more commonly in women with HIV? 1. Syphilis 2. Toxoplasmosis 3. Gonorrhea 4. Herpes

Answer: 2 Explanation: 2. Women with HIV should be evaluated and treated for other sexually transmitted infections and for conditions occurring more commonly in women with HIV, such as tuberculosis, cytomegalovirus, toxoplasmosis, and cervical dysplasia.

The nurse is caring for a client in the clinic whom she suspects has vaginosis. Which test best determines whether this sexually active woman has the disorder? 1. The observation of mycelia upon direct microscopy in a 10% potassium hydroxide preparation 2. The addition of a 10% potassium hydroxide solution to the vaginal secretions 3. A vaginal pH of less than 4.5 4. A Gram stain positive for the fungus

Answer: 2 Explanation: 2. Adding a 10% potassium hydroxide solution to the vaginal secretion of a client with bacterial vaginosis, called a "whiff" test, produces a fishy smell.

One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.

Answer: 2 Explanation: 2. Administering intravenous acyclovir (Zovirax) and contact precautions are appropriate measures for an infant at risk for developing herpes simplex 2 infection.

The nurse is caring for a client hospitalized for pelvic inflammatory disease. Which nursing intervention would have priority? 1. Encourage oral fluids 2. Administer cefotetan IV 3. Enforce bed rest 4. Remove IUC, if present

Answer: 2 Explanation: 2. Administration of medications to treat the disease is the first priority.

The pregnant client at 14 weeks' gestation is in the clinic for a regular prenatal visit. Her mother also is present. The grandmother-to-be states that she is quite uncertain about how she can be a good grandmother to this baby because she works full-time. Her own grandmother was retired, and was always available when needed by a grandchild. What is the nurse's best response to this concern? 1. "Don't worry. You'll be a wonderful grandmother. It will all work out fine." 2. "What are your thoughts on what your role as grandmother will include?" 3. "As long as there is another grandmother available, you don't have to worry." 4. "Grandmothers are supposed to be available. You should retire from your job."

Answer: 2 Explanation: 2. Although relationships with parents can be very complex, the expectant grandparents often become increasingly supportive of the expectant couple, even if conflicts previously existed. But it can be difficult for even sensitive grandparents to know how deeply to become involved in the childrearing process. In some areas, classes for grandparents provide information about changes in birthing and parenting practices.

The nurse expects an initial weight loss for the average postpartum client to be which of the following? 1. 5 to 8 pounds 2. 10 to 12 pounds 3. 12 to 15 pounds 4. 15 to 20 pounds

Answer: 2 Explanation: 2. An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid.

Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do? 1. Be used in place of preoperative sedation 2. Result in neonatal respiratory depression 3. Prevent the need for anesthesia with an episiotomy 4. Enhance uterine contractions

Answer: 2 Explanation: 2. Analgesia given too late is of no value to the woman and may cause neonatal respiratory depression.

During labor, the fetus was in a brow presentation, but after a prolonged labor, the fetus converted to face presentation and was delivered vaginally with forceps assist. What should the nurse explain to the parents? 1. The infant will need to be observed for meconium aspiration. 2. Facial edema and head molding will subside in a few days. 3. The infant will be given prophylactic antibiotics. 4. Breastfeeding will need to be delayed for a day or two.

Answer: 2 Explanation: 2. Any facial edema and head molding that result from the use of forceps at birth will subside in a few days.

Approximately 80% of anovulatory women have which condition? 1. Turner syndrome 2. Polycystic ovary syndrome (PCOS) 3. Klinefelter syndrome 4. Fragile X syndrome

Answer: 2 Explanation: 2. Approximately 80% of anovulatory women have polycystic ovary syndrome (PCOS), causing insulin resistance and hyperinsulinemia.

Upon delivery of the newborn, what nursing intervention most promotes parental attachment? 1. Placing the newborn under the radiant warmer. 2. Placing the newborn on the mother's abdomen. 3. Allowing the mother a chance to rest immediately after delivery. 4. Taking the newborn to the nursery for the initial assessment.

Answer: 2 Explanation: 2. As the baby is placed on the mother's abdomen or chest, she frequently reaches out to touch and stroke her baby. When the newborn is placed in this position, the father or partner also has a very clear, close view and can also reach out to touch the baby.

The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? 1. Client at 5 cm requesting labor epidural analgesia 2. Client whose cervix remains at 6 cm for 4 hours 3. Client who has developed nausea and vomiting 4. Client requesting her partner to stay with her

Answer: 2 Explanation: 2. Average cervical change in the active phase of the first stage of labor is 1.2 cm/hour; thus, this client's lack of cervical change is unexpected, and should be reported to the supervisor.

The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Encourage the husband to remain in the room. 2. Keep the client on bed rest at this time. 3. Apply an internal fetal scalp electrode. 4. Obtain a clean-catch urine specimen.

Answer: 2 Explanation: 2. Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse.

The nurse is presenting a class to pregnant clients. The nurse asks, "The fetal brain is developing rapidly, and the nervous system is complete enough to provide some regulation of body function on its own, at which fetal development stage?" It is clear that education has been effective when a participant makes which response? 1. "The 17th-20th week" 2. "The 25th-28th week" 3. "The 29th-32nd week" 4. "The 33rd-36th week"

Answer: 2 Explanation: 2. Between the 25th and 28th week, the brain is developing rapidly, and the nervous system is complete enough to provide some degree of regulation of body functions.

A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? 1. Stop breastfeeding and switch to formula. 2. Eliminate dairy products from her diet. 3. Supplement breastfeeding with a soy-based formula. 4. Offer the baby water between feedings.

Answer: 2 Explanation: 2. Breastfeeding babies may not be allergic to the mother's milk but rather to the cow's milk protein (an antigen) in the mother's milk. By eliminating the culprit (e.g., the bovine protein) from the mother's diet and therefore from the breast milk, the mother can continue to breastfeed, providing optimal nutrition and immune factors to her infant.

Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth

Answer: 2 Explanation: 2. Breastfeeding should be initiated within the first hour of life unless medically contraindicated.

The homecare nurse is seeing a client at 6 weeks postpartum. Which statement by the client indicates the need for immediate intervention? 1. "The baby sleeps 7 hours each night now." 2. "My flow is red, and I need to wear a pad." 3. "My breasts no longer leak between feedings." 4. "I started back on the pill 2 weeks ago."

Answer: 2 Explanation: 2. By 6 weeks postpartum, lochia should be absent or minimal in amount, requiring only a pantiliner. Red, heavy flow is not an expected finding, and requires intervention.

To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following? 1. Address pain early 2. Change peri-pads frequently 3. Avoid overhydration 4. Report symptoms of uterine cramping

Answer: 2 Explanation: 2. Changing peri-pads frequently decreases skin contact with a moist medium that favors bacteria growth.

A newly diagnosed insulin-dependent type 1 diabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. What would the best explanation include? 1. "Your baby could be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "As long as you control your blood sugar, your baby will not be affected at all." 4. "Your baby might have high blood sugar for several days."

Answer: 2 Explanation: 2. Characteristically, infants of mothers with diabetes are large for gestational age (LGA) as a result of high levels of fetal insulin production stimulated by the high levels of glucose crossing the placenta from the mother. Sustained fetal hyperinsulinism and hyperglycemia ultimately lead to excessive growth, called macrosomia, and deposition of fat.

The nurse is assessing a woman at 10 weeks' gestation who is addicted to alcohol. The woman asks the nurse, "What is the point of stopping drinking now if my baby probably has been hurt by it already?" What is the best response by the nurse? 1. "It won't help your baby, but you will feel better during your pregnancy if you stop now." 2. "If you stop now, you and your baby have less chance of serious complications." 3. "If you limit your drinking to once a week, your baby will be okay." 4. "You might as well stop it now, because once your baby is born, you'll have to give up alcohol if you plan on breastfeeding."

Answer: 2 Explanation: 2. Chronic abuse of alcohol can undermine maternal health by causing malnutrition, bone marrow suppression, increased incidence of infections, and liver disease. The effects of alcohol on the fetus may result in fetal alcohol spectrum disorders (FASD).

The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? 1. Elation, euphoria, and talkativeness 2. A sense of failure and loss 3. Questions about whether or not to circumcise 4. Uncertainty surrounding the baby's name

Answer: 2 Explanation: 2. Clients who participate in childbirth classes that stress the normalcy of birth may feel a sense of loss or failure if an intervention is used during their labor or birth.

What is required for any women receiving oxytocin (Pitocin)? 1. CPR 2. Continuous electronic fetal monitoring 3. Administering oxygen by mask 4. Nonstress test

Answer: 2 Explanation: 2. Continuous electronic fetal monitoring (EFM) is required for any women receiving oxytocin (Pitocin).

The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? 1. Offer a pacifier 2. Burp the newborn 3. Unwrap the newborn 4. Stroke the newborn's spine and feet

Answer: 2 Explanation: 2. Crying results in increased ingestion of air even before the infant has started feeding. Infants who are very hungry also gulp more air. For these situations, instruct the parents to burp their infant frequently.

The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring client who will have a forceps delivery. Which action or assessment finding requires intervention? 1. Regional anesthesia is administered via pudendal block. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. The client's bladder is emptied using a straight catheter.

Answer: 2 Explanation: 2. During the contraction, as the forceps are applied, the woman should avoid pushing.

When planning care for a client who has undergone an episiotomy, it would be important for the nurse to include a goal that addresses the need for pain relief of which part of the body? 1. Mons pubis 2. Perineal body 3. Labia minora 4. Hymen

Answer: 2 Explanation: 2. During the last part of labor, the perineal body thins out until it is just a few centimeters thick. This tissue is often the site of an episiotomy or lacerations during childbirth.

The nurse is preparing an education session for women on the prevention of urinary tract infections (UTIs). Which statement should be included? 1. Lower urinary tract infections rarely occur in women. 2. The most common causative organism of cystitis is E. coli. 3. Wiping from back to front after a BM will help prevent a UTI. 4. Back pain often develops with a lower urinary tract infection.

Answer: 2 Explanation: 2. E. coli is present in 75% to 90% of women with UTIs.

A client is concerned about her risk for breast cancer. Following the initial history, the nurse identifies which of the following as a high risk factor for breast cancer? 1. History of late menarche and early menopause 2. Sister who has had breast cancer 3. Mother with fibrocystic breast disease 4. Multiparity

Answer: 2 Explanation: 2. Family history of first-degree relative (mother, sister, or daughter) with breast cancer increases the risk of breast cancer with the number of first-degree relatives with breast cancer.

The postpartum homecare client asks the nurse why the visit is taking place. Which response is best? 1. "We make homecare visits to reinforce any teaching that you didn't quite grasp in the hospital." 2. "We make homecare visits to verify that both you and the baby are safe and doing well." 3. "We make homecare visits to ensure you are breastfeeding correctly." 4. "We make homecare visits to thoroughly assess your baby to make sure he is growing."

Answer: 2 Explanation: 2. Family well-being should be determined through a comprehensive assessment that includes physical, emotional, and social functioning.

A pregnant woman tells the nurse-midwife, "I've heard that if I eat certain foods during my pregnancy, the baby will be a boy." The nurse-midwife's response should explain that this is a myth, and that the sex of the baby is determined at what time? 1. At the time of ejaculation 2. At fertilization 3. At the time of implantation 4. At the time of differentiation

Answer: 2 Explanation: 2. Fertilization is the point at which the sex of the zygote is determined.

The client at 39 weeks' gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention? 1. The baby's hands and feet are blue at 1 minute after birth. 2. The fetal heart rate is 70 prior to making the skin incision. 3. Clear fluid is obtained from the baby's oropharynx. 4. The neonate cries prior to delivery of the body.

Answer: 2 Explanation: 2. Fetal bradycardia occurs when the fetal heart rate falls below 110 beats/minute during a 10-minute period of continuous monitoring. When fetal bradycardia is accompanied by decreased variability, it is considered ominous and could be a sign of fetal compromise.

The physician has determined the need for forceps. The nurse should explain to the client that the use of forceps is indicated because of which of the following? 1. Her support person is exhausted 2. Premature placental separation 3. To shorten the first stage of labor 4. To prevent fetal distress

Answer: 2 Explanation: 2. Fetal conditions indicating the need for forceps include premature placental separation, prolapsed umbilical cord, and nonreassuring fetal status.

A client who is experiencing her first pregnancy has just completed the initial prenatal examination with a certified nurse-midwife. Which statement indicates that the client needs additional information? 1. "Because we heard the baby's heartbeat, I am undoubtedly pregnant." 2. "Because I haven't felt the baby move yet, we don't know whether I'm pregnant." 3. "My last period was 2 months ago, which means I'm 2 months along." 4. "The increased size of my uterus means that I am finally pregnant."

Answer: 2 Explanation: 2. Fetal movement is a subjective, or presumptive, change of pregnancy, and is not a reliable indicator in the early months of pregnancy.

A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? 1. Test with a HIV serologic test at 8 months. 2. Begin prophylactic AZT (Zidovudine) administration. 3. Provide 4 to 5 large feedings throughout the day. 4. Encourage the mother to breastfeed the child.

Answer: 2 Explanation: 2. For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon after birth as possible and continuing for 6 weeks.

During a class on genetics for pregnant families, the nurse is discussing the how the egg and sperm are formed before fertilization takes place. The nurse explains that these cells have only half the number of chromosomes, so when fertilization takes place, there will be the correct number. What is the process by which the egg and sperm are formed called? 1. Oogenesis 2. Gametogenesis 3. Meiosis 4. Spermatogenesis

Answer: 2 Explanation: 2. Gametogenesis is the process by which ovum and sperm are produced.

The client at 9 weeks' gestation has been told that her HIV test was positive. The client is very upset, and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the client makes which statement? 1. "I cannot take the medications that control HIV during my pregnancy, because they will harm the baby." 2. "My baby can get HIV during the pregnancy and through my breast milk." 3. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 4. "The HIV won't affect my baby, and I will have a low-risk pregnancy without additional testing."

Answer: 2 Explanation: 2. HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth.

The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately? 1. The client who describes feeling sad all the time 2. The client who reports hearing voices talking about the baby 3. The client who states she has no appetite and wants to sleep all day 4. The client who says she needs a refill on her sertraline (Zoloft) next week

Answer: 2 Explanation: 2. Hearing voices is an indication the client is experiencing postpartum psychosis, and is the highest priority because the voices might tell her to harm her baby.

A client at 16 weeks' gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change? 1. "Because of your pregnancy, you're not making enough red blood cells." 2. "Because your blood volume has increased, your hematocrit count is lower." 3. "This change could indicate a serious problem that might harm your baby." 4. "You're not eating enough iron-rich foods like meat."

Answer: 2 Explanation: 2. Hemoglobin and hematocrit levels drop in early to mid-pregnancy as a result of pregnancy-associated hemodilution. Because the plasma volume increase (50%) is greater than the erythrocyte increase (25%), the hematocrit decreases slightly.

A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. What should the nurse's response be? 1. "Heparin is used when coagulation problems are resolved." 2. "Heparin is safer because it does not cross the placenta." 3. "They are the same drug, but heparin is less expensive." 4. "Coumadin interferes with iron absorption in the intestines."

Answer: 2 Explanation: 2. Heparin is safest for the client to take because it does not cross the placental barrier.

The nurse is admitting a client who is 12 weeks pregnant and an IV drug user. She has had a number of sexual partners, complains of malaise, and has yellow in the eyes, nausea, and vomiting. Having obtained this history, the nurse suspects that the client has which condition? 1. Hepatitis E 2. Hepatitis C 3. Gonorrhea 4. Hepatitis A

Answer: 2 Explanation: 2. Hepatitis C is bloodborne, and found in drug users and those who have multiple sexual partners.

The client has undergone an ultrasound, which estimated fetal weight at 4500 g (9 pounds 14 ounces). Which statement indicates that additional teaching is needed? 1. "Because my baby is big, I am at risk for excessive bleeding after delivery." 2. "Because my baby is big, his blood sugars could be high after he is born." 3. "Because my baby is big, my perineum could experience trauma during the birth." 4. "Because my baby is big, his shoulders could get stuck and a collarbone broken."

Answer: 2 Explanation: 2. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus.

The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction? 1. "The en face position promotes bonding and attachment." 2. "Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed." 3. "In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous." 4. "The needs of the mother and of her infant are balanced during the phase of mutual regulation."

Answer: 2 Explanation: 2. Ideally, initial skin-to-skin contact is immediate. The benefits of this practice are supported by a preponderance of evidence.

A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, what should the nurse also say? 1. "Your baby will be fine. We'll start IV, and get this stopped in no time at all." 2. "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." 3. "You are going to miscarry. But you should be relieved because most miscarriages are the result of abnormalities in the fetus." 4. "I really can't say. However, when your physician comes, I'll ask her to talk to you about it."

Answer: 2 Explanation: 2. If bleeding persists and abortion is imminent or incomplete, the woman may be hospitalized, IV therapy or blood transfusions may be started to replace fluid, and dilation and curettage (D&C) or suction evacuation is performed to remove the remainder of the products of conception.

The physicians/CNM opts to use a vacuum extractor for a delivery. What does the nurse understand? 1. There is little risk with vacuum extraction devices. 2. There should be further fetal descent with the first two "pop-offs." 3. Traction is applied between contractions. 4. The woman often feels increased discomfort during the procedure.

Answer: 2 Explanation: 2. If more than three "pop-offs" occur (the suction cup pops off the fetal head), the procedure should be discontinued. Page Ref: 641

A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborn's head is delivered.

Answer: 2 Explanation: 2. If the infant has absent or depressed respirations, heart rate less than 100 beats/min, or poor muscle tone, direct tracheal suctioning by specially trained personnel is recommended.

A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following? 1. Estrogen 2. Human chorionic gonadotropin (hCG) 3. Progesterone 4. Luteinizing hormone

Answer: 2 Explanation: 2. If the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete human chorionic gonadotropin (hCG), which is needed to maintain the corpus luteum.

A client is to receive fertility drugs prior to in vitro fertilization. What is the expected action of this medication? 1. Prolonging of the luteal phase 2. Stimulation of ovulation 3. Suppression of menstruation 4. Promotion of cervical mucus production

Answer: 2 Explanation: 2. In IVF, a woman's ovaries are stimulated by a combination of medications, one or more oocytes are aspirated from her ovaries and fertilized in the laboratory, and then they are placed into her uterus after normal embryo development has begun.

The nurse is preparing a class for expectant fathers. Which information should the nurse include? 1. Siblings adjust readily to the new baby. 2. Sexual activity is safe for normal pregnancy. 3. The expectant mother decides the feeding method. 4. Fathers are expected to be involved in labor and birth.

Answer: 2 Explanation: 2. In a healthy pregnancy, there is no medical reason to limit sexual activity.

A Chinese woman who is 12 weeks pregnant reports to the nurse that ginseng and bamboo leaves help reduce her anxiety. How should the nurse respond to this client? 1. Advise the client to give up the bamboo leaves but to continue taking ginseng. 2. Advise the client to give up all herbal remedies. 3. Tell the client that her remedies have no scientific foundation. 4. Assess where the client obtains her remedy, and investigate the source.

Answer: 2 Explanation: 2. In some cases, the nurse might want to suggest remedies that may be more effective than herbal remedies. However, if the home remedy is not harmful, there is no reason for the nurse to ask a client to discontinue this practice.

A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? 1. Second phase 2. Latent phase 3. Active phase 4. Transition phase

Answer: 2 Explanation: 2. In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions.

Which of the following would be considered a clinical sign of hemorrhage? 1. Increased blood pressure 2. Increasing pulse 3. Increased urinary output 4. Hunger

Answer: 2 Explanation: 2. Increasing pulse, widening pulse pressure would be considered a clinical sign of hemorrhage.

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? 1. A history of obsessive-compulsive disorder (OCD) 2. Chlamydia 3. Delivered six other children by cesarean section 4. A urinary tract infection (UTI)

Answer: 2 Explanation: 2. Infants born to mothers with chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and require close observation of the respiratory status and eyes. Page

The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? 1. The sterile vaginal exam 2. Welcoming the couple 3. Auscultation of the fetal heart rate 4. Checking for ruptured membranes

Answer: 2 Explanation: 2. It is important to establish rapport and to create an environment in which the family feels free to ask questions. The support and encouragement of the nurse in maintaining a caring environment begin with the initial admission.

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change.

Answer: 2 Explanation: 2. It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema.

5) What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? 1. Colostrum 2. Lactose 3. Lactoferrin 4. Secretory IgA

Answer: 2 Explanation: 2. Lactose is the primary carbohydrate in mammalian milk.

Late preterm infants have higher infant morbidity and mortality rates than term infants. Which of the following complications can they experience? 1. Hyperglycemia 2. Jaundice 3. Motor difficulties 4. Sensory complications

Answer: 2 Explanation: 2. Late preterm infants can experience jaundice.

A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and that over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? 1. Engagement 2. Lightening 3. Molding 4. Braxton Hicks contractions

Answer: 2 Explanation: 2. Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet.

The need for forceps has been determined. The client's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate? 1. Input 2. Low 3. Mid 4. Outlet

Answer: 2 Explanation: 2. Low forceps are applied when the leading edge of the fetal head is at +2 station.

A couple who have sought fertility counseling have been told that the man's sperm count is very low. The nurse advises the couple that spermatogenesis is impaired when which condition occurs? 1. The vas deferens is ligated. 2. Male obesity is present. 3. The prostate gland is enlarged. 4. The flagella are segmented.

Answer: 2 Explanation: 2. Male obesity is associated with poor spermatogenesis and increased amount of time to conception.

The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? 1. Assist the client to empty her bladder 2. Help the client back to bed to check the fundus 3. Assess her blood pressure and pulse 4. Begin an IV of lactated Ringer's solution

Answer: 2 Explanation: 2. Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts.

The laboring client brought a written birth plan indicating that she wanted to avoid pain medications and an epidural. She is now at 6 cm and states, "I can't stand this anymore! I need something for pain! How will an epidural affect my baby?" What is the nurse's best response? 1. "The narcotic in the epidural will make both you and the baby sleepy." 2. "It is unlikely that an epidural will decrease your baby's heart rate." 3. "Epidurals tend to cause low blood pressure in babies after birth." 4. "I can't get you an epidural, because of your birth plan."

Answer: 2 Explanation: 2. Maternal hypotension results in uteroplacental insufficiency in the fetus, which is manifested as late decelerations on the fetal monitoring strip. The risk of hypotension can be minimized by hydrating the vascular system with 500 to 1000 mL of IV solution before the procedure and changing the woman's position and/or increasing the IV rate afterward.

The nurse is providing follow-up education to a client just diagnosed with vaginal herpes. What statement by the client verifies correct knowledge about vaginal herpes? 1. "I should douche daily to prevent infection." 2. "I could have another breakout during my period." 3. "I am more likely to develop cancer of the cervix." 4. "I should use sodium bicarbonate on the lesions to relieve discomfort."

Answer: 2 Explanation: 2. Menstruation seems to trigger recurrences of herpes.

Mild or chronic anemia in an infant may be treated adequately which of the following? 1. Transfusions with O-negative or typed and cross-matched packed red cells 2. Iron supplements or iron-fortified formulas 3. Steroid therapy 4. Antibiotics or antivirals

Answer: 2 Explanation: 2. Mild or chronic anemia in an infant may be treated adequately with iron supplements or iron-fortified formulas.

A pregnant client who swims 3-5 times per week asks the nurse whether she should stop this activity. What is the appropriate nursing response? 1. "You should decrease the number of times you swim per week." 2. "Continuing your exercise program would be beneficial." 3. "You should discontinue your exercise program immediately." 4. "You should consider a less strenuous type of exercise."

Answer: 2 Explanation: 2. Mild to moderate exercise is beneficial during pregnancy. Regular exercise-at least 30 minutes of moderate exercise daily or at least most days of the week-is preferred.

The nurse is preparing a class on reproduction. What is the cell division process that results in two identical cells, each with the same number of chromosomes as the original cell called? 1. Meiosis 2. Mitosis 3. Oogenesis 4. Gametogenesis

Answer: 2 Explanation: 2. Mitosis results in the production of diploid body (somatic) cells, which are exact copies of the original cell.

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe 2. Begin phototherapy 3. Begin blood exchange transfusion 4. Stop breastfeeding

Answer: 2 Explanation: 2. Neonatal hyperbilirubinemia must be considered pathologic if the serum bilirubin concentration is rising by more than 0.2 mg/dL per hour. If the newborn is over 24 hours old, which is past the time where an increase in bilirubin would result from pathologic causes, phototherapy may be the treatment of choice to prevent the possible complications of kernicterus.

A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor? 1. Nausea 2. Bladder distention 3. Uterine atony 4. Hypertension

Answer: 2 Explanation: 2. Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention.

The nurse should anticipate the labor pattern for a fetal occiput posterior position to be which of the following? 1. Shorter than average during the latent phase 2. Prolonged as regards the overall length of labor 3. Rapid during transition 4. Precipitous

Answer: 2 Explanation: 2. Occiput posterior (OP) position of the fetus is the most common fetal malposition and occurs when the head remains in the direct OP position throughout labor. This can prolong the overall length of labor.

A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? 1. Orange juice 2. Milk 3. Decaffeinated tea 4. Water

Answer: 2 Explanation: 2. Often fussy breastfeeding or cow's milk-based formula-fed infants are switched to a lactose-free formula because of concerns about lactose intolerance.

The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? 1. Habituation 2. Orientation 3. Self-quieting 4. Reactivity

Answer: 2 Explanation: 2. Orientation is the newborn's ability to be alert to, to follow, and to fixate on complex visual stimuli that have a particular appeal and attraction. The newborn prefers the human face and eyes, and bright shiny objects.

The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? 1. "This condition occurs more frequently among Japanese people." 2. "We must be very careful to avoid most proteins to prevent brain damage." 3. "Carbohydrates can cause our baby to develop cataracts and liver damage." 4. "Our baby's thyroid gland isn't functioning properly."

Answer: 2 Explanation: 2. PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain tissue leads to progressive, irreversible intellectual disability.

To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? 1. Keep the baby in the room at all times. 2. Check the identification of all personnel who transport the newborn. 3. Place a "No Visitors" sign on the door. 4. Keep the baby in the nursery at all times.

Answer: 2 Explanation: 2. Parent should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance.

The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Entrance wound present below the umbilicus." 3. "Client is positioned in a left lateral tilt." 4. "Clear fluid is leaking from the vagina."

Answer: 2 Explanation: 2. Penetrating trauma includes gunshot wounds and stab wounds. The mother generally fares better than the fetus if the penetrating trauma involves the abdomen as the enlarged uterus is likely to protect the mother's bowel from injury.

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? 1. "Jaundice is uncommon in newborns." 2. "Some newborns require phototherapy." 3. "Jaundice is a medical emergency." 4. "Jaundice is always a sign of liver disease."

Answer: 2 Explanation: 2. Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a sign of liver disease. Physiologic jaundice might require phototherapy.

A new mother is concerned about spoiling her newborn. The home care nurse teaches the mother which of the following? 1. Newborns can be manipulative, so caution is advised. 2. Meeting the infant's needs develops a trusting relationship. 3. An infant who is rocked to sleep every night is being spoiled. 4. Crying is good for babies, and letting them cry it out is advised.

Answer: 2 Explanation: 2. Picking babies up when they cry teaches them that adults are responsive to their needs. This helps build a sense of trust and security.

What type of forceps are designed to be used with a breech presentation? 1. Midforceps 2. Piper 3. Low 4. High

Answer: 2 Explanation: 2. Piper forceps are designed to be used with a breech presentation. They are applied after the birth of the body, when the fetal head is still in the birth canal and assistance is needed.

The nurse's response to a client with a history of pelvic inflammatory disease who is trying to get pregnant is based on the knowledge that which condition can contribute to an infertility problem? 1. Hepatitis 2. Postinfection tubal damage 3. Pelvic abscess 4. Tubal infection

Answer: 2 Explanation: 2. Postinfection tubal damage is the most likely cause, as the infection causes tubal damage, which can lead to infertility.

The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? 1. "I should use only soy-based formula for the first year." 2. "I follow the instructions for mixing the powdered formula exactly." 3. "It is okay to add more water to the formula to make it last longer." 4. "The mixed formula can be left on the counter for a day."

Answer: 2 Explanation: 2. Powdered formula is the least expensive type of formula. Parents will need to be briefed on safety precautions during formula preparation and they should be instructed to follow the directions on the formula package label precisely as written.

Couples at risk for having a detectable single gene or chromosomal anomaly may wish to undergo which procedure? 1. Preimplantation genetic screening (PGS) 2. Preimplantation genetic diagnosis (PGD) 3. Intracytoplasmic sperm injection (ICSI) 4. Gamete intrafallopian transfer (GIFT)

Answer: 2 Explanation: 2. Preimplantation genetic diagnosis (PGD) is a term used when one or both genetic parents carry a gene mutation and testing is performed to determine whether that mutation or unbalanced chromosomal compliment has been passed to the oocyte or embryo.

The nurse is reviewing assessment data from several different male clients. Which one should receive information about causes of infertility? 1. Circumcised client 2. Client with a history of premature ejaculation 3. Client with a history of measles at age 12 4. Client employed as an engineer

Answer: 2 Explanation: 2. Premature ejaculation is a possible cause of infertility.

A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone? 1. Estrogen 2. Progesterone 3. FSH 4. LH

Answer: 2 Explanation: 2. Progesterone is often called the hormone of pregnancy because it inhibits uterine contractions and relaxes smooth muscle to cause vasodilation, allowing pregnancy to be maintained.

The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? 1. Providing skin-to-skin contact 2. Swaddling the newborn in a blanket 3. Unwrapping the newborn 4. Allowing the newborn to feel and smell the mother's breast

Answer: 2 Explanation: 2. Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. Swaddling the newborn has the opposite effect.

The client delivered 30 minutes ago. Her blood pressure and pulse are stable. Vaginal bleeding is scant. The nurse should prepare for which procedure? 1. Abdominal hysterectomy 2. Manual removal of the placenta 3. Repair of perineal lacerations 4. Foley catheterization

Answer: 2 Explanation: 2. Retention of the placenta beyond 30 minutes after birth is termed retained placenta. Manual removal of the placenta is then performed.

The client demonstrates that the nurse's teaching regarding ways to prevent a recurrence of her urinary tract infection was effective when she makes which statement? 1. "I should wipe from back to front after urination." 2. "I should urinate when I feel the urge." 3. "I should try to restrict my intake of fruits." 4. "I should use a diaphragm."

Answer: 2 Explanation: 2. Retention overdistends the bladder, and can lead to infection.

Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? 1. Place the client in McRoberts position. 2. Watch for the emergence of the placenta. 3. Prepare for the delivery of an undiagnosed twin. 4. Place the client in a supine position.

Answer: 2 Explanation: 2. Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina.

On examination of the prenatal client, the nurse is aware that she will assess for a bluish pigmentation of the vagina. What is this objective (probable) sign of pregnancy also known as? 1. Hegar sign 2. Chadwick sign 3. Nightingale sign 4. Goodell sign

Answer: 2 Explanation: 2. The blue-purple discoloration of the cervix is Chadwick sign.

The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? 1. She puts the infant to breast when he is asleep to help wake him up. 2. She takes off her gown to achieve skin-to-skin contact. 3. She leans toward the infant so that he turns his head to access the nipple. 4. The infant is crying when he is brought to the breast.

Answer: 2 Explanation: 2. Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding.

A client who is in the second trimester of pregnancy tells the nurse that she has developed a darkening of the line in the midline of her abdomen from the symphysis pubis to the umbilicus. What other expected changes during pregnancy might she also notice? 1. Lightening of the nipples and areolas 2. Reddish streaks called striae on her abdomen 3. A decrease in hair thickness 4. Small purplish dots on her face and arms

Answer: 2 Explanation: 2. Striae, or stretch marks, are reddish, wavy, depressed streaks that may occur over the abdomen, breasts, and thighs as pregnancy progresses.

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? 1. "My baby will be able to focus on my face when she is about a month old." 2. "My baby might startle a little if a loud noise happens near him." 3. "Newborns prefer sour tastes." 4. "Our baby won't have a sense of smell until she is older."

Answer: 2 Explanation: 2. Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex are other ways to soothe the newborn. The settled newborn is then able to attend to and interact with the environment.

The homecare nurse is examining a newborn who is sleeping on a pillow in a basket, covered with a fluffy blanket. There is also a stuffed animal in the basket. The most important nursing action is to do which of the following? 1. Remove the stuffed animal from the basket and place it on the floor. 2. Teach the parents the risk of SIDS from soft items in the infant's bed. 3. Make certain that the blanket is firmly tucked under the baby. 4. Ask whether the color of the blanket has cultural significance.

Answer: 2 Explanation: 2. Teaching the parents about the risk of sudden infant death syndrome (SIDS) is the highest priority.

After a sex education class at a high school, the nurse overhears a student discussing safe sex practices. Which statement indicates that teaching was successful? 1. "I don't have to worry about getting infected if I have oral sex." 2. "Teen women are the group at highest risk for sexually transmitted infections." 3. "The best thing to do if I have sex a lot is to use spermicide each and every time." 4. "Boys get the HIV virus more easily than girls do."

Answer: 2 Explanation: 2. Teens with multiple sex partners are more susceptible to sexually transmitted diseases.

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place 2. Axillary temperature 99.7°F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement

Answer: 2 Explanation: 2. Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7°F-98.6°F. Vital signs should be monitored every 4 hours with axillary temperatures.

What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old

Answer: 2 Explanation: 2. Temperature instability is often seen with sepsis. Fever is rare in a newborn.

A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? 1. To provide analgesia 2. To relax the uterus 3. To induce labor 4. To prevent hemorrhage

Answer: 2 Explanation: 2. Terbutaline is administered to achieve uterine relaxation.

Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? 1. ABM 2. WIC 3. ILCA 4. LLLI

Answer: 2 Explanation: 2. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs.

The nurse anticipates that the physician will most likely order a cervicovaginal fetal fibronectin test for which client? 1. The client at 34 weeks' gestation with gestational diabetes 2. The client at 32 weeks' gestation with regular uterine contractions 3. The client at 37 weeks' multi-fetal gestation 4. The client at 20 weeks' gestation with ruptured amniotic membranes

Answer: 2 Explanation: 2. The absence of cervicovaginal fFN between 20 and 34 weeks' gestation has been shown to be a strong predictor of a woman not experiencing preterm birth due to spontaneous preterm labor or premature rupture of membranes. Positive findings indicate a 99% probability of birth within the next 2 weeks.

Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician and clarify the order for which client? 1. A gravida with intrauterine growth restriction 2. A gravida with mild hypotension of pregnancy 3. A gravida who is postterm 4. A gravida who complains of decreased fetal movement for 2 days

Answer: 2 Explanation: 2. The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypotension will need to be monitored more closely throughout the pregnancy, but is not a candidate at present for a biophysical profile.

The nurse receives a phone call from a 25-year-old woman experiencing breast tenderness in the week prior to her menses, with palpable breast nodularity, without nipple discharge. What is the best response by the nurse? 1. "Please make an appointment at the breast cancer center as soon as possible." 2. "How much salty food do you regularly consume?" 3. "As long as you don't have nipple discharge, it isn't a serious condition." 4. "Eliminate caffeine and chocolate from your diet."

Answer: 2 Explanation: 2. The client is describing fibrocystic breast changes. A salt restriction with a mild diuretic taken the week before menstrual bleeding often improves the condition.

The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 3. Coping: Family, Compromised, related to labor process 4. Knowledge, Deficient, related to lack of information about normal labor process and comfort measures

Answer: 2 Explanation: 2. The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor.

Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert her attention to other subjects. 2. Review the documentation of the birth experience and discuss it with her. 3. Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. 4. Submit a referral to Social Services because of possible obsessive behavior.

Answer: 2 Explanation: 2. The client may talk about her labor and birth experience. The nurse should provide opportunities to discuss the birth experience in a nonjudgmental atmosphere if the woman desires to do so.

The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? 1. Apply an internal fetal monitor. 2. Monitor the client using electronic fetal monitoring. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a upright, sitting position.

Answer: 2 Explanation: 2. The client should be monitored using electronic fetal monitoring for at least 30 minutes and up to 2 hours after placement to assess the contraction pattern and the fetal status.

The nurse is seeing clients in the women's clinic. Which client should be treated with ceftriaxone IM and doxycycline orally? 1. A pregnant client with gonorrhea and a yeast infection 2. A nonpregnant client with gonorrhea and chlamydia 3. A pregnant client with syphilis 4. A nonpregnant client with chlamydia and trichomoniasis

Answer: 2 Explanation: 2. The combined treatment of ceftriaxone IM and doxycycline orally provides dual treatment for gonorrhea and chlamydia, which frequently occur together.

A client at 36 weeks' gestation is complaining of dyspnea when lying flat. What is the clinical reason for this complaint? 1. Maternal hypertension 2. Fundal height 3. Hydramnios 4. Congestive heart failure

Answer: 2 Explanation: 2. The dyspnea is resulting from the pressure of the enlarging uterus on the diaphragm.

A client at 10 weeks' gestation has developed cholecystitis. If surgery is required, what is the safest time during pregnancy? 1. Immediately, before the fetus gets any bigger 2. Early in the second trimester 3. As close to term as possible 4. The risks are too high to do it anytime in pregnancy

Answer: 2 Explanation: 2. The early second trimester is the best time to operate because there is less risk of spontaneous abortion or early labor, and the uterus is not so large as to impinge on the abdominal field.

The external and internal female reproductive organs develop and mature in response to what hormones? 1. Adrenocorticotropic hormones (ACTH) 2. Estrogen and progesterone 3. Steroid hormones 4. Luteinizing hormones (LH)

Answer: 2 Explanation: 2. The external and internal female reproductive organs develop and mature in response to estrogen and progesterone.

The female and male reproductive organs are homologous, which means what? 1. They are believed to cause vasoconstriction and muscular contraction 2. They are fundamentally similar in function and structure 3. They are rich in sebaceous glands 4. They are target organs for estrogenic hormones

Answer: 2 Explanation: 2. The female and male reproductive organs are homologous; that is, they are fundamentally similar in function and structure.

A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? 1. "Don't worry. Babies go through a lot of these little phases." 2. "Your son is in the sleep phase. He'll wake up soon." 3. "Your son is exhausted from being born, and will sleep 6 more hours." 4. "Your breastfeeding efforts have caused excessive fatigue in your son."

Answer: 2 Explanation: 2. The first period of reactivity lasts approximately 30 minutes after birth. During this period the newborn is awake and active and may appear hungry and have a strong sucking reflex. After approximately half an hour, the newborn's activity gradually diminishes, and the heart rate and respirations decrease as the newborn enters the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours.

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? 1. "I will call your pediatrician immediately." 2. "Passage of the first stool within 48 hours is normal." 3. "Your newborn might not have a stool until the third day." 4. "Your newborn must be dehydrated."

Answer: 2 Explanation: 2. The first voiding should occur within 24 hours and first passage of stool within 48 hours.

) The nurse has presented a community education class on recommended health screenings for women. Which statement about the Pap smear by a class member indicates that additional teaching is necessary? 1. "It is recommended for women 21 years of age and older." 2. "It diagnoses cervical cancer." 3. "Intercourse at a young age is a risk factor for an abnormal Pap smear." 4. "Detects abnormal cells."

Answer: 2 Explanation: 2. The focus of the Pap smear is the detection of high-grade cervical disease. It does not diagnose cervical cancer.

In succenturiate placenta, one or more accessory lobes of fetal villi have developed on the placenta, with vascular connections of fetal origin. What is the gravest maternal danger? 1. Cord prolapse 2. Postpartum hemorrhage 3. Paroxysmal hypertension 4. Brachial plexus injury

Answer: 2 Explanation: 2. The gravest maternal danger is postpartum hemorrhage if this minor lobe is severed from the placenta and remains in the uterus.

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate

Answer: 2 Explanation: 2. The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn.

A fetal weight is estimated at 4490 grams in a client at 38 weeks' gestation. Counseling should occur before labor regarding which of the following? 1. Mother's undiagnosed diabetes 2. Likelihood of a cesarean delivery 3. Effectiveness of epidural anesthesia with a large fetus 4. Need for early delivery

Answer: 2 Explanation: 2. The likelihood of a cesarean delivery with a fetus over 4000 grams is high. This should be discussed with the client before labor.

A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? 1. Stop breastfeeding 2. Provide newborn supplements to the newborn 3. Offer whole milk 4. Supplement with skim milk

Answer: 2 Explanation: 2. The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn. Vitamins in human milk are influenced by the mother's vitamin intake, general nutritional status, and genetic differences.

The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? 1. Temperature 97.9°F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min

Answer: 2 Explanation: 2. The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.

An infertile couple confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions facing them. Which nursing strategy would be most appropriate? 1. Refer them to a marriage counselor. 2. Provide them with information and instructions throughout the diagnostic and therapeutic process. 3. Express concern and caring. 4. Inquire about the names they have chosen for their baby.

Answer: 2 Explanation: 2. The nurse can provide comfort to couples by offering a sympathetic ear, a nonjudgmental approach, and appropriate information and instruction throughout the diagnostic and therapeutic processes.

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? 1. Heart rate 120 2. Temperature 96.8°F 3. Respiratory rate 50 4. Temperature 99.6°F

Answer: 2 Explanation: 2. The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the baby's axillary temperature is below 36.5°C (97.7°F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia.

A 26-year-old client is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client? 1. "Exercise either just before meals or wait until 2 hours after a meal." 2. "Carry hard candy (or other simple sugar) when exercising." 3. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." 4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk."

Answer: 2 Explanation: 2. The nurse should advise her to carry a simple sugar such as hard candy because of the possibility of exercise-induced hypoglycemia.

A 16-year-old pregnant client is seen at her 10-weeks'-gestation visit. She tells the nurse that she felt the baby move that morning. What response by the nurse is appropriate? 1. "That is very exciting. The baby must be very healthy." 2. "Would you please describe what you felt for me?" 3. "That is impossible. The baby is not big enough yet." 4. "Would you please let me see whether I can feel the baby?"

Answer: 2 Explanation: 2. The nurse should ask the client to describe what she felt, as 10 weeks' gestation is too early to feel fetal movement.

An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? 1. Do not add food supplements to the baby's diet. 2. Place soiled diapers in a sealed plastic bag. 3. Wash soiled linens in cool water with bleach. 4. Shield the baby's eyes from bright lights.

Answer: 2 Explanation: 2. The nurse should instruct the parents about proper hand-washing techniques, about proper disposal of soiled diapers, and to wear gloves when diapering.

Nurses who are interacting with expectant families from a different culture or ethnic group can provide more effective, culturally sensitive nursing care by doing what? 1. Recognizing that ultimately it is the family's right to make a woman's healthcare choices. 2. Obtaining a medical interpreter of the language the client speaks. 3. Evaluating whether the client's healthcare beliefs have any positive consequences for her health. 4. Accepting personal biases, attitudes, stereotypes, and prejudices.

Answer: 2 Explanation: 2. The nurse should provide for the services of an interpreter if language barriers exist

The pregnant client has asked the nurse what kinds of medications cause birth defects. Which statement would best answer this question? 1. "Birth defects are very rare. Don't worry; your doctor will watch for problems." 2. "To be safe, don't take any medication without talking to your doctor." 3. "Too much vitamin C is one of the most common issues." 4. "Almost all medications will cause birth defects in the first trimester."

Answer: 2 Explanation: 2. The nurse should remind the client of the need to check with her caregiver about medications. If a woman has taken a drug in category D or X, she should be informed of the risks associated with that drug and of her alternatives.

During a prenatal examination, an adolescent client asks, "How does my baby get air?" What correct information would the nurse give? 1. "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences." 2. "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream." 3. "The blood from the placenta is carried through the umbilical artery, which penetrates the abdominal wall of the fetus." 4. "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy."

Answer: 2 Explanation: 2. The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into the maternal bloodstream.

The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues? 1. "I am so happy and blessed to have my new baby." 2. "One minute I'm laughing and the next I'm crying." 3. "My husband is helping out by changing the baby at night." 4. "Breastfeeding is going quite well now that the engorgement is gone."

Answer: 2 Explanation: 2. The postpartum blues consist of a transient period of depression that occurs during the first few days of puerperium. Symptoms may include mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown.

The nurse teaching a high school class explains that during the menstrual cycle, the endometrial glands begin to enlarge under the influence of estrogen and cervical mucosal changes occur; the changes peak at ovulation. In which phase of the menstrual cycle does this occur? 1. Menstrual 2. Proliferative 3. Secretory 4. Ischemic

Answer: 2 Explanation: 2. The proliferative phase begins when the endometrial glands begin to enlarge under the influence of estrogen and cervical mucosal changes occur; the changes peak at ovulation.

A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, what would the nurse expect to do? 1. Observe fetal heart rate variability 2. Hydrate the vascular system with 500-1000 mL of intravenous fluids 3. Place the client in the semi-Fowler's position 4. Teach the client appropriate breathing techniques

Answer: 2 Explanation: 2. The risk of hypotension can be minimized by hydrating the vascular system with 500 to 1000 mL of IV solution before the procedure and changing the woman's position and/or increasing the IV rate afterward.

A prenatal educator is asking a partner about normal psychological adjustment of an expectant mother during the second trimester of pregnancy. Which answer by the partner would indicate a typical expectant mother's response to pregnancy? 1. "She is very body-conscious, and hates every little change." 2. "She daydreams about what kind of parent she is going to be." 3. "I haven't noticed anything. I just found out she was pregnant." 4. "She has been having dreams at night about misplacing the baby."

Answer: 2 Explanation: 2. The second trimester brings increased introspection and consideration of how she will parent. She might begin to get furniture and clothing as concrete preparation, and feels movement and is aware of the fetus and incorporates it into herself.

The nurse is teaching the students in their obstetric rotation about fertilization. What processes must the sperm undergo before fertilization can occur? 1. Capacitation and ovulation 2. Capacitation and the acrosomal reaction 3. Oogenesis and the acrosomal reaction 4. Gametogenesis and capacitation

Answer: 2 Explanation: 2. The sperm must undergo two processes before fertilization can occur: capacitation and the acrosomal reaction.

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score? 1. 7 2. 8 3. 9 4. 10

Answer: 2 Explanation: 2. The strong cry earns 2 points. The crying with foot sole stimulation earns 2 points. The limb flexion and resistance earn 2 points each. Bluish color earns 0 points. The Apgar score is 8.

The true moment of fertilization occurs when what happens? 1. Cortical reaction occurs 2. Nuclei unite 3. Spermatozoa propel themselves up the female tract 4. Sperm surrounding the ovum release their enzymes

Answer: 2 Explanation: 2. The true moment of fertilization occurs as the nuclei unite. Their individual nuclear membranes disappear, and their chromosomes pair up to produce the diploid zygote.

The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Give 1 liter of lactated Ringer's solution IV. 3. Administer 30 mL Maalox (magnesium hydroxide) orally. 4. Encourage clear liquids orally.

Answer: 2 Explanation: 2. The vital signs indicate hypovolemia from dehydration, which leads to hypotension and increased pulse rate. Giving this client a liter of lactated Ringer's solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.

The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first? 1. Woman who is 2nd day post-cesarean, moderate lochia serosa 2. Woman day of delivery, fundus firm 2 cm above umbilicus 3. Woman who had a cesarean section, 1st postpartum day, 4 cm diastasis recti abdominis 4. Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants

Answer: 2 Explanation: 2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. If the fundus is in the midline but higher than expected, it is usually associated with clots within the uterus.

The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. "The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

Answer: 2 Explanation: 2. This explanation is accurate and easy for the client to understand. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin.

The adolescent client reports to the clinic nurse that her period is late, but that her home pregnancy test is negative. What should the nurse explain that these findings most likely indicate? 1. "This means you are not pregnant." 2. "You might be pregnant, but it might be too early for your home test to be accurate." 3. "We don't trust home tests. Come to the clinic for a blood test." 4. "Most people don't use the tests correctly. Did you read the instructions?"

Answer: 2 Explanation: 2. This is a true statement. Most home pregnancy tests have low false-positive rates, but the false-negative rate is slightly higher. Repeating the test in a week is recommended.

The client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? 1. "Unless you have pain with urination, we don't need to worry about it." 2. "These symptoms usually mean the baby's head has descended further." 3. "Come in for an appointment today and we'll check everything out." 4. "This might indicate that the baby is no longer in a head-down position."

Answer: 2 Explanation: 2. This is the best response because it most directly addresses what the client has reported.

A woman pregnant with twins asks the nurse about differences between identical and fraternal twins. The nurse explains that since it has been determined that she is having a boy and a girl, they are fraternal, and will have with of the following? 1. One placenta, two amnions, and two chorions 2. Two placentas, two amnions, and two chorions 3. Two placentas, one amnion, and two chorions 4. Two placentas, two amnions, one chorion

Answer: 2 Explanation: 2. This is the correct answer. Fraternal twins have two placentas, two amnions, and two chorions, however, the placentas sometimes fuse and look as if they are one.

At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual

Answer: 2 Explanation: 2. This newborn's weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life.

The nurse is making a postpartum home visit in the summer. The new father asks about taking the baby to a family outing this weekend. The nurse should encourage the father to do which of the following? 1. Cover the infant with dark blankets to block the sun. 2. Keep the infant in the shade. 3. Uncover the infant's head to prevent hyperthermia. 4. Avoid taking the infant outdoors for 6 months.

Answer: 2 Explanation: 2. To prevent sunburn, the newborn should remain shaded, wear a light layer of clothing, or be protected with sunscreen specifically formulated for infants.

Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply? 1. "I'm checking the blood vessels in the cord to see whether it has one artery and one vein." 2. "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein." 3. "I'm checking the blood vessels in the cord to see whether it has two veins and one artery." 4. "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins."

Answer: 2 Explanation: 2. Two arteries and one vein are present in a normal umbilical cord.

The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "A small cup will be put onto the baby's head, and a gentle suction will be applied." 2. "I can stop pushing and just rest if the vacuum extractor is used." 3. "The baby's head might have some swelling from the vacuum cup." 4. "The vacuum will be applied for a total of ten minutes or less."

Answer: 2 Explanation: 2. Vacuum extraction is an assistive delivery. The physician/CNM applies traction in coordination with uterine contractions.

A woman is 32 weeks pregnant. She is HIV-positive but asymptomatic. The nurse knows what would be important in managing her pregnancy and delivery? 1. An amniocentesis at 30 and 36 weeks 2. Weekly non-stress testing beginning at 32 weeks' gestation 3. Application of a fetal scalp electrode as soon as her membranes rupture in labor 4. Administration of intravenous antibiotics during labor and delivery

Answer: 2 Explanation: 2. Weekly non-stress testing (NST) is begun at 32 weeks' gestation and serial ultrasounds are done to detect IUGR.

The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which statement made by the client indicates to the nurse that the client has understood the teaching? 1. "I can continue to drink alcohol until I am diagnosed as pregnant." 2. "I need to stop drinking alcohol completely when I start trying to get pregnant." 3. "A beer once a week will not damage the fetus." 4. "I can drink alcohol while breastfeeding because it doesn't pass into breast milk."

Answer: 2 Explanation: 2. Women should discontinue drinking alcohol when they start to attempt to become pregnant due to possible effects of alcohol on the fetus.

The nurse teaches a client that luteinizing hormone (LH) is important in the ovarian cycle for which purposes? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Proliferation of the endometrial mucosa 2. Ovulation 3. Corpus luteum development 4. Maturation of the ovarian follicle 5. Cyclic changes that allow pregnancy not to occur

Answer: 2, 3 Explanation: 2. During the follicular phase, the primordial follicle matures under the influence of FSH and LH until ovulation occurs. 3. The corpus luteum develops under the influence of LH during the luteal phase.

The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. High fever 2. Frequency 3. Suprapubic pain 4. Chills 5. Nausea and vomiting

Answer: 2, 3 Explanation: 2. Frequency is characteristic of acute cystitis. 3. Suprapubic pain is characteristic of acute cystitis.

The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. To be sure she gets a kosher diet. 2. Expect that most visitors will be women. 3. Uncover only the necessary skin when assessing. 4. The father will take an active role in infant care. 5. She will prefer a male physician.

Answer: 2, 3 Explanation: 2. In Muslim cultures, emphasis on childrearing and infant care activities is on the mother and female relatives. 3. Women of the Islamic faith may have specific modesty requirements; the woman must be completely covered, with only her feet and hands exposed.

A client comes to the clinic complaining of a thick, white, tenacious discharge and vulvular soreness. Which medication treatment will the nurse teach the client about? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Silver sulfadiazine 2. Metronidazole 3. Clindamycin cream 4. Ceftriaxone sodium 5. Doxycycline

Answer: 2, 3 Explanation: 2. Metronidazole is the preferred treatment for vulvovaginal candidiasis. 3. Although less effective than metronidazole, clindamycin cream can be used to treat vulvovaginal candidiasis.

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalohematoma or excessive bruising 5. Cyanosis

Answer: 2, 3 Explanation: 2. Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. 3. Jaundice is a yellowish coloration of the skin and sclera of the eyes that develops from the deposit of yellow pigment bilirubin in lipid/fat-containing tissues.

) The client presents to the clinic for an initial prenatal examination. She asks the nurse whether there might be a problem for her baby because she has type B Rh-positive blood and her husband has type O Rh-negative blood, or because her sister's baby had ABO incompatibility. What is the nurse's best answer? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Your baby would be at risk for Rh problems if your husband were Rh-negative." 2. "Rh problems only occur when the mother is Rh-negative and the father is not." 3. "ABO incompatibility occurs only after the baby is born." 4. "We don't know for sure, but we can test for ABO incompatibility." 5. "Your husband's being type B puts you at risk for ABO incompatibility."

Answer: 2, 3 Explanation: 2. Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive. 3. ABO incompatibility is limited to type O mothers with a type A or B fetus and occurs after the baby is born.

Under which circumstances would the nurse remove prostaglandin from the client's cervix? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Contractions every 5 minutes 2. Nausea and vomiting 3. Uterine tachysystole 4. Cardiac tachysystole 5. Baseline fetal heart rate of 140-148

Answer: 2, 3, 4 Explanation: 2. A reason to remove prostaglandin from a client's cervix is the presence of nausea and vomiting. 3. A reason to remove prostaglandin from a client's cervix is uterine tachysystole. 4. A reason to remove prostaglandin from a client's cervix is cardiac tachysystole.

The nurse recognizes that subjective pregnancy changes such as amenorrhea can be caused by which conditions? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Goodell sign 2. Anemia 3. Pseudocyesis 4. Thyroid dysfunction 5. Fetal heartbeat

Answer: 2, 3, 4 Explanation: 2. Anemia can cause amenorrhea, and is a subjective sign of pregnancy. 3. Pseudocyesis (intense desire for pregnancy) can cause amenorrhea. 4. Thyroid dysfunction can cause amenorrhea, and is a subjective sign of pregnancy.

Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home.

Answer: 2, 3, 4 Explanation: 2. Folding the diaper down to prevent coverage of the cord stump can prevent contamination of the area and promote drying. 3. Keeping the umbilical stump clean and dry can reduce the risk of infection. 4. It is the nurse's responsibility to instruct parents in caring for the cord and observing for signs and symptoms of infection after discharge, such as foul smell, redness and greenish yellow drainage, localized heat and tenderness, or bright red bleeding or if the area remains unhealed 2 to 3 days after the cord has sloughed off.

A pregnant client has been admitted with a diagnosis of hyperemesis. Which orders written by the primary healthcare provider are the highest priorities for the nurse to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Obtain complete blood count. 2. Start intravenous fluid with multivitamins. 3. Check admission weight. 4. Obtain urine for urinalysis. 5. Give a medication to stop the nausea and vomiting.

Answer: 2, 5 Explanation: 2. Starting intravenous fluid with multivitamins is a priority if the client has been vomiting. 5. Giving a medication to stop the nausea and vomiting is a priority.

Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins

Answer: 2, 3, 4 Explanation: 2. Infectious disease screening results help to determine if the infant is also at risk of obtaining any infectious diseases. 3. Gestational diabetes is a risk factor for the newborn. 4. Prolonged rupture of the membranes is a possible risk factor for the infant.

The nurse knows that which of the following are advantages of spinal block? Note: Credit will be given only if all correct answers and no incorrect answers are selected. Select all that apply. 1. Intense blockade of sympathetic fibers 2. Relative ease of administration 3. Maternal compartmentalization of the drug 4. Immediate onset of anesthesia 5. Larger drug volume

Answer: 2, 3, 4 Explanation: 2. One of advantages of spinal block is the relative ease of administration. 3. One of the advantages of spinal block is the maternal compartmentalization of the drug. 4. One of the advantages of spinal block is the immediate onset of anesthesia.

Absolute contraindications to exercise while pregnant include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Abruptio placentae 2. Placenta previa after 26 weeks' gestation 3. Preeclampsia-eclampsia 4. Cervical insufficiency (cerclage) 5. Intrauterine growth restriction (IUGR)

Answer: 2, 3, 4 Explanation: 2. Placenta previa after 26 weeks' gestation is an absolute contraindication to exercise. 3. Preeclampsia-eclampsia is an absolute contraindication to exercise. 4. Cervical insufficiency (cerclage) is an absolute contraindication to exercise.

The nurse is preparing a brochure for couples considering pregnancy after the age of 35. Which statements should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. There is a decreased risk of Down syndrome. 2. Preexisting medical conditions can complicate pregnancy. 3. Preterm births are more common. 4. Amniocentesis can be performed to detect genetic anomalies. 5. The increased fertility of women over age 35 makes conception easier.

Answer: 2, 3, 4 Explanation: 2. Preexisting medical conditions, such as hypertension or diabetes, probably play a more significant role than age in maternal well-being and the outcome of pregnancy. 3. The incidence of low-birth-weight infants, preterm births, miscarriage, stillbirth, and perinatal morbidity and mortality is higher among women age 35 or older. 4. Amniocentesis is offered to all women over age 35 to permit the early detection of several chromosomal abnormalities, including Down syndrome; noninvasive analysis of fetal nucleic acid is now commonly recommended to women of advanced maternal age.

A pregnant client complains to the clinic nurse that her varicose veins are causing more discomfort than before. Which recommendations does the nurse make to the client? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Increase the time she stands. 2. Walk on a daily basis. 3. Not cross her legs at the knees. 4. Wear support hose. 5. Hyperextend her knee with her feet up.

Answer: 2, 3, 4 Explanation: 2. Regular exercise, such as swimming, cycling, or walking, promotes venous return, which helps prevent varicosities. 3. The client should avoid crossing her legs at the knees because of the pressure it puts on her veins. 4. Supportive hose or elastic stockings may be extremely helpful.

Nonreassuring fetal status often occurs with a tachysystole contraction pattern. Intrauterine resuscitation measures may become warranted and can include which of the following measures? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Position the woman on her right side. 2. Apply oxygen via face mask. 3. Call for anesthesia provider for support. 4. Increase intravenous fluids by at least 700 mL bolus. 5. Call the physician/CNM to the bedside.

Answer: 2, 3, 4 Explanation: 2. The nurse would apply oxygen via face mask. 3. The nurse would call for anesthesia provider for support. 4. The nurse would increase intravenous fluids by at least 500 mL bolus.

In providing community education about hepatitis, the nurse includes information on the chronic forms of hepatitis. A form of hepatitis that becomes chronic is which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D 5. Hepatitis E

Answer: 2, 3, 4 Explanation: 2. Unlike hepatitis A infection, hepatitis B infection is chronic. 3. Unlike hepatitis A infection, hepatitis C infection is chronic. 4. Unlike hepatitis A infection, hepatitis D infection is chronic.

The nurse knows that the maternal risks associated with postterm pregnancy include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Polyhydramnios 2. Maternal hemorrhage 3. Maternal anxiety 4. Forceps-assisted delivery 5. Perineal damage

Answer: 2, 3, 4, 5 Explanation: 2. Maternal symptoms and complications in postterm pregnancy may include maternal hemorrhage. 3. Maternal symptoms and complications in postterm pregnancy may include maternal anxiety. 4. Maternal symptoms and complications in postterm pregnancy may include an operative vaginal birth with forceps or vacuum extractor. 5. Maternal symptoms and complications in postterm pregnancy may include perineal trauma and damage.

The nurse educator teaching reproductive anatomy wants to make sure the students understand what stabilizes the uterus. Which statements about the individual ligaments would the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The infundibulopelvic ligaments suspend and support the uterus. 2. The broad ligament keeps the uterus centrally placed. 3. The uterosacral ligaments sweep back around the rectum and insert on the sides of the first and second sacral vertebrae. 4. The ovarian ligaments anchor the ovary to the uterus. 5. The cardinal ligaments prevent uterine prolapse and support the upper vagina.

Answer: 2, 3, 4, 5 Explanation: 2. The broad ligament keeps the uterus centrally placed. 3. The uterosacral ligaments sweep back around the rectum and insert on the sides of the first and second sacral vertebrae. 4. The ovarian ligaments anchor the ovary to the uterus. 5. The cardinal ligaments prevent uterine prolapse and support the upper vagina.

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "We should keep our home air-conditioned so the baby doesn't overheat." 2. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 3. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 4. "If the baby's body temperature gets too low, he will warm himself up without any shivering." 5. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."

Answer: 2, 3, 4, 5 Explanation: 2. The newborn is particularly prone to heat loss by evaporation immediately after birth and during baths; thus drying the newborn is critical. 3. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 4. Nonshivering thermogenesis (NST), an important mechanism of heat production unique to the newborn, is the major mechanism through which heat is produced. 5. A decrease in the environmental temperature of 2°C is a drop sufficient to double the oxygen consumption of a term newborn and can cause the newborn to show signs of respiratory distress.

Which of the following potential problems would the nurse consider when planning care for a client with a persistent occiput posterior position of the fetus? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased fetal mortality 2. Severe perineal lacerations 3. Ceasing of labor progress 4. Fetus born in posterior position 5. Intense back pain during labor

Answer: 2, 3, 4, 5 Explanation: 2. The woman can have third- or fourth-degree perineal laceration or extension of a midline episiotomy. 3. Sometimes labor progress ceases if the fetus fails to rotate to an occiput anterior position. 4. Occiput posterior positions are associated with a higher incidence of vacuum-assisted births. 5. The woman usually experiences intense back pain in the small of her back throughout labor.

The nurse is aware of the different breathing techniques that are used during labor. Why are breathing techniques used during labor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. They are a form of anesthesia. 2. They are a source of relaxation. 3. They increase the ability to cope with contractions. 4. They are a source of distraction. 5. They increase a woman's pain threshold.

Answer: 2, 3, 4, 5 Explanation: 2. When used correctly, breathing techniques can encourage relaxation. 3. When used correctly, breathing techniques can enhance the ability to cope with uterine contractions. 4. When used correctly, breathing techniques provide some distraction from the pain. 5. When used correctly, breathing techniques increase a woman's pain threshold.

Which of the following symptoms would be an indication of postpartum blues? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Overeating 2. Anger 3. Mood swings 4. Constant sleepiness 5. Crying

Answer: 2, 3, 5 Explanation: 2. Anger would be a symptom of postpartum blues. 3. Mood swings would be a symptom of postpartum blues. 5. Weepiness and crying would be a symptom of postpartum blues.

Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cover the newborn's eyes at all times, even when not under the lights. 2. Close the newborn's eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.

Answer: 2, 3, 5 Explanation: 2. Apply eye patches over the newborn's closed eyes during exposure to banks of phototherapy. 3. Discontinue conventional phototherapy and remove the eye patches at least once per shift to assess the eyes for the presence of conjunctivitis. 5. Repositioning allows equal exposure of all skin areas and prevents pressure areas.

A pregnant client at 28 weeks' gestation asks the nurse what her baby is like at this stage of pregnancy. How would the nurse describe the fetus? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The fetus is developing subcutaneous fat. 2. The fetus is now opening and closing her eyes. 3. The baby could now breathe on her own, if she were born. 4. The fetus has fingernails and toenails. 5. The fetus is forming surfactant needed for lung function.

Answer: 2, 3, 5 Explanation: 2. At 28 weeks, the eyes begin to open and close. 3. At 28 weeks, the delivered baby can breathe. 5. At 28 weeks, the fetus has the surfactant formed needed for breathing.

Which of the following would be considered normal newborn urinalysis values? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Color bright yellow 2. Bacteria 0 3. Red blood cells (RBC) 0 4. White blood cells (WBC) more than 4-5/hpf 5. Protein less than 5-10 mg/dL

Answer: 2, 3, 5 Explanation: 2. Bacteria value should be 0. 3. Red blood cells (RBC) should be 0. 5. Protein less than 5-10 mg/dL would be considered normal.

The clinic nurse is teaching a pregnant client about her iron supplement. Which information is included in the teaching? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Iron does not affect the gastrointestinal tract. 2. A stool softener might be needed. 3. Start a low dose, and increase it gradually. 4. Expect the stools to be black and bloody. 5. Iron absorption is poor if taken with meals.

Answer: 2, 3, 5 Explanation: 2. Constipation can be a problem when taking iron, so a stool softener might be needed. 3. To prevent anemia, experts recommend that all pregnant women start on 30 mg/day of iron supplements daily. If anemia is diagnosed, the dosage should be increased to 60 to 120 mg per day of iron. 5. Iron absorption is reduced by 40% to 50% if taken with meals.

The nurse working with pediatric clients knows that the primary hormone secretions that induce puberty include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Thyroid hormone 2. Follicle-stimulating hormone 3. Leuteinizing hormone 4. Adrenocorticotropic hormone 5. Gonadotropin-releasing hormones

Answer: 2, 3, 5 Explanation: 2. Follicle-stimulating hormone (FSH) is part of the process that induces puberty. 3. The luteinizing hormone (LH) is a part of the process that induces puberty. 5. The central nervous system releases a neurotransmitter that stimulates the hypothalamus to synthesize and release gonadotropin-releasing hormone (GnRH).

A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Schedule care throughout the day. 2. Silence alarms quickly. 3. Place a blanket over the top portion of the incubator. 4. Do not offer a pacifier. 5. Dim the lights.

Answer: 2, 3, 5 Explanation: 2. Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. 3. Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. 5. Dimming the lights may encourage infants to open their eyes and be more responsive to their parents.

The nurse is evaluating the goal "Client will remain free of opportunistic infections" for an HIV-positive pregnant client. The nurse determines the goal was met when the client has which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. An absolute CD4+ T-lymphocyte count below 200 2. No complaint of chills or fever during the pregnancy 3. Weight gain of 30 lbs during the pregnancy 4. ESR above 20 mm/hr 5. Normal erythrocyte sedimentation rate maintained during the pregnancy

Answer: 2, 3, 5 Explanation: 2. Not having chills, fever, or a sore throat throughout the pregnancy is an indication the client did not have an infection. 3. Weight gain of 25 to 35 pounds is normal for a pregnancy. This client met the goal for nutrition and remaining infection-free. 5. Having a normal erythrocyte sedimentation rate during the pregnancy is an expected outcome.

Maternal risks of occiput posterior (OP) malposition include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Blood loss greater than 1000 mL 2. Postpartum infection 3. Anal sphincter injury 4. Higher rates of vaginal birth 5. Instrument delivery

Answer: 2, 3, 5 Explanation: 2. Postpartum infection is a maternal risk of OP. 3. Anal sphincter injury is a maternal risk of OP. 5. Instrument delivery is a maternal risk of OP.

Nursing interventions that foster the process of becoming a mother include which of the following? 1. Encouraging detachment from the nurse-patient relationship 2. Promoting maternal-infant attachment 3. Building awareness of and responsiveness to infant interactive capabilities 4. Instruct about promoting newborn independence 5. Preparing the woman for the maternal social role

Answer: 2, 3, 5 Explanation: 2. Promoting maternal-infant attachment is a nursing intervention that fosters the process of becoming a mother. 3. Building awareness of and responsiveness to infant interactive capabilities is a nursing intervention that fosters the process of becoming a mother. 5. Preparing the woman for the maternal social role is a nursing intervention that fosters the process of becoming a mother.

Under the influence of progesterone, which of the following occur? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Temperature decreases 2. Cervix secretes thick, viscous mucus 3. Breasts prepare for lactation 4. Breast glandular tissue decreases in size 5. Vaginal epithelium proliferates

Answer: 2, 3, 5 Explanation: 2. Under the influence of progesterone, the cervix secretes thick, viscous mucus. 3. Under the influence of progesterone, breasts prepare for lactation. 5. Under the influence of progesterone, vaginal epithelium proliferates.

The nurse in the prenatal clinic will tell the client at 38-weeks' gestation to lie on her left side when the client complains of which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Nausea 2. Pallor 3. Clamminess 4. Constipation 5. Dizziness

Answer: 2, 3, 5 Explanation: 2. Vena caval syndrome can cause pallor, which is relieved when the client turns to lie on her left side. 3. Vena caval syndrome can cause clamminess, which is relieved when the client turns to lie on her left side. 5. Vena caval syndrome can cause dizziness, which is relieved when the client turns to lie on her left side.

Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Elevated blood pressure 2. Fundus firm and midline 3. Moderate amount of lochia serosa 4. Edema and bruising of perineum 5. Inflamed hemorrhoids

Answer: 2, 4 Explanation: 2. A firm fundus that is midline indicates the normal progression of uterine involution. 4. During the early postpartum period, the soft tissue in and around the perineum may appear edematous with some bruising.

The nurse is assessing a new client in the clinic. The nurse knows that the subjective (presumptive) signs and symptoms of pregnancy include which of the following? 1. Positive urine pregnancy test, enlarged abdomen, and Braxton Hicks contractions 2. Positive urine pregnancy test, amenorrhea, changes in pigmentation of the skin, and softening of the cervix 3. Increase in urination, amenorrhea, fatigue, breast tenderness, and quickening 4. Enlarged abdomen and fetal heartbeat

Answer: 3 Explanation: 3. An increase in urination, amenorrhea, fatigue, breast tenderness, and quickening are all subjective (presumptive) changes of pregnancy.

A male client visits the infertility clinic for the results of his comprehensive exam. The exam indicated oligospermia. The client asks the nurse which procedure would assist him and his wife to conceive. The nurse's best response would include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "You might want to consider adoption." 2. "An option you might consider is in vitro fertilization." 3. "Surrogacy might be your best option." 4. "Many couples utilize therapeutic husband insemination." 5. "The GIFT procedure has had much success."

Answer: 2, 4 Explanation: 2. The in vitro fertilization procedure is used in cases in which infertility has resulted from male infertility. 4. Therapeutic husband insemination is generally indicated for such seminal deficiencies as oligospermia.

In which clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Placental abruption 2. Meconium-stained fluid 3. Polyhydramnios 4. Variable decelerations 5. Early decelerations

Answer: 2, 4 Explanation: 2. The physician may order amnioinfusion for meconium-stained fluid. 4. Amnioinfusion is sometimes done to prevent the possibility of variable decelerations.

The nurse interviews a 28-year-old client with a new medical diagnosis of endometriosis. Which question asked by the nurse is appropriate? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. "Are you having hot flashes?" 2. "Are you experiencing pain during intercourse?" 3. "Is a vaginal discharge present?" 4. "Are you having pain during your period?" 5. "Have you noticed any skin rashes?"

Answer: 2, 4 Explanation: 2. The primary symptoms of endometriosis include dyspareunia. 4. The primary symptoms of endometriosis include dysmenorrhea.

A couple is at the clinic for preconceptual counseling. Both parents are 40 years old. The nurse knows that the education session has been successful when the wife makes which statement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "We are at low risk for having a baby with Down syndrome." 2. "Our children are more likely to have genetic defects." 3. "Children born to parents this age have sex-linked disorders." 4. "The tests for genetic defects can be done early in pregnancy." 5. "It will be almost impossible for us to conceive a child."

Answer: 2, 4 Explanation: 2. Women 35 or older are at greater risk for having children with chromosome abnormalities. 4. Genetic testing such as amniocentesis and chorionic villus sampling are done in the first trimester.

The nurse determines that a client is carrying her fetus in the vertical (longitudinal) lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Sacrum 2. Left arm 3. Mentum 4. Left scapula 5. Right scapula

Answer: 2, 4, 5 Explanation: 2. A fetus with an arm presenting is likely in a horizontal lie. 4. A fetus with a left scapula presenting is in a horizontal lie. 5. A fetus with a right scapula presenting is in a horizontal lie.

The nurse is monitoring a client who is receiving an amnioinfusion. Which assessments must the nurse perform to prevent a serious complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Color of amniotic fluid 2. Maternal blood pressure 3. Cervical effacement 4. Uterine resting tone 5. Fluid leaking from the vagina

Answer: 2, 4, 5 Explanation: 2. Blood pressure should be monitored along with other vital signs. 4. The nurse should monitor contraction status (frequency, duration, intensity, resting tone, and associated maternal discomfort). 5. The nurse should continually check to make sure the infused fluid is being expelled from the vagina.

During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Establish a therapeutic relationship with her physician 2. Adapt to altered lifestyles and family structure resulting from the addition of a new member 3. Restore her intellectual abilities 4. Restore physical condition 5. Develop competence in caring for and meeting the needs of her infant

Answer: 2, 4, 5 Explanation: 2. During the first several postpartum weeks, the new mother must adapt to altered lifestyles and family structure resulting from the addition of a new member. 4. During the first several postpartum weeks, the new mother must restore her physical condition. 5. During the first several postpartum weeks, the new mother must develop competence in caring for and meeting the needs of her infant.

) Risk factors for labor dystocia include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tall maternal height 2. Labor induction 3. Small-for-gestational-age (SGA) fetus 4. Malpresentation 5. Prolonged latent phase

Answer: 2, 4, 5 Explanation: 2. Labor induction is a risk factor of dystocia. 4. Malpresentation is a risk factor of dystocia. 5. Prolonged latent phase is a risk factor of dystocia.

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Respiratory rate of 66 breaths per minute 2. Periodic breathing with pauses of 25 seconds 3. Synchronous chest and abdomen movements 4. Grunting on expiration 5. Nasal flaring

Answer: 2, 4, 5 Explanation: 2. Periodic breathing with pauses longer than 20 seconds (apnea) is an abnormal finding that should be reported to the physician. 4. Grunting on expiration is an abnormal finding that should be reported to the physician. 5. Nasal flaring is an abnormal finding that should be reported to the physician.

Which of the following are considered risk factors for development of severe hyperbilirubinemia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Northern European descent 2. Previous sibling received phototherapy 3. Gestational age 27 to 30 weeks 4. Exclusive breastfeeding 5. Infection

Answer: 2, 4, 5 Explanation: 2. Previous sibling received phototherapy is considered a risk factor for development of severe hyperbilirubinemia. 4. Exclusive breastfeeding, particularly if nursing is not going well and excessive weight loss is experienced, is considered a risk factor for development of severe hyperbilirubinemia. 5. Infection is considered a risk factor for development of severe hyperbilirubinemia.

Benefits of skin-to-skin care as a developmental intervention include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Routine discharge 2. Stabilization of vital signs 3. Increased periods of awake-alert state 4. Decline in the episodes of apnea and bradycardia 5. Increased growth parameters

Answer: 2, 4, 5 Explanation: 2. Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. 4. Decline in the episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention. 5. Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention.

What are the three functions of cervical mucosa? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Form the relatively fixed axis of the birth passage 2. Provide lubrication for the vaginal canal 3. Provide nourishment and protective maternal antibodies to infants 4. Provide an alkaline environment to shelter deposited sperm from the acidic vaginal secretions 5. Act as a bacteriostatic agent

Answer: 2, 4, 5 Explanation: 2. The cervical mucosa provides lubrication for the vaginal canal. 4. The cervical mucosa provides an alkaline environment to shelter deposited sperm from the acidic vaginal secretions. 5. The cervical mucosa acts as a bacteriostatic agent.

Amniotomy as a method of labor induction has which of the following advantages? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The danger of a prolapsed cord is decreased. 2. There is usually no risk of hypertonus or rupture of the uterus. 3. The intervention can cause a decrease in pain. 4. The color and composition of amniotic fluid can be evaluated. 5. The contractions elicited are similar to those of spontaneous labor.

Answer: 2, 4, 5 Explanation: 2. There is usually no risk of hypertonus or rupture of the uterus and this is an advantage of amniotomy. 4. The color and composition of amniotic fluid can be evaluated and this is an advantage of amniotomy. 5. The contractions elicited are similar to those of spontaneous labor and this is an advantage of amniotomy.

A client at 40 weeks' gestation is to undergo stripping of the membranes. The nurse provides the client with information about the procedure. Which information is accurate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Intravenous administration of oxytocin will be used to initiate contractions. 2. The physician/CNM will insert a gloved finger into the cervical os and rotate the finger 360 degrees. 3. Stripping of the membranes will not cause discomfort, and is usually effective. 4. Labor should begin within 24-48 hours after the procedure. 5. Uterine contractions, cramping, and a bloody discharge can occur after the procedure.

Answer: 2, 4, 5 Explanation: 2. This motion separates the amniotic membranes that are lying against the lower uterine segment and internal os from the distal part of the lower uterine segment. 4. If labor is initiated, it typically begins within 24-48 hours. 5. Uterine contractions, cramping, scant bleeding, and bloody discharge can occur after stripping of the membranes.

An anesthesiologist informs the nurse that a client scheduled for a caesarean section will be having general anesthesia with postoperative self-controlled analgesia. For which clients would a general anesthesia be recommended? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The client with a history of hypertension 2. The client who has had a lower back fusion 3. The client who is 13 years old 4. The client who is allergic to morphine sulfate 5. The client who has had surgery for scoliosis

Answer: 2, 5 Explanation: 2. Contraindications for epidural block include patients with previous back surgery. 5. Contraindications for epidural block include patients with previous back surgery.

The primary physician orders a narcotic analgesic for a client in labor. Which situations would lead the nurse to hold the medication? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Contraction pattern every 3 minutes for 60 seconds 2. Fetal monitor tracing showing late decelerations 3. Client sleeping between contractions 4. Blood pressure 150/90 5. Blood pressure 80/42

Answer: 2, 5 Explanation: 2. Maternal hypotension results in uteroplacental insufficiency in the fetus, which is manifested as late decelerations on the fetal monitoring strip. 5. This would be a contraindication, as a narcotic can lower the blood pressure even more.

A client is being admitted to the labor area with the diagnosis of eclampsia. Which actions by the nurse are appropriate at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails. 3. Have the woman sit up. 4. Provide the client with grief counseling. 5. The airway should be maintained and oxygen administered.

Answer: 2, 5 Explanation: 2. Side rails should be up and padded. 5. Suctioning may be necessary to keep the airway clear.

Whether sensitization is the result of a blood transfusion or maternal-fetal hemorrhage for any reason, what test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed? 1. Indirect Coombs' test 2. Nonstress test 3. Kleihauer-Betke or rosette test 4. Direct Coombs' test

Answer: 3 Explanation: 3. A Kleihauer-Betke or rosette test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed.

The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? 1. "The next time I have a baby, I can try to deliver vaginally." 2. "The risk of rupturing my uterus is too high for me to have any more babies." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "I can only have one more baby."

Answer: 3 Explanation: 3. A classic uterine incision is made in the upper uterine segment and is associated with an increased risk of rupture in subsequent pregnancy, labor, and birth. Therefore, subsequent deliveries will be done by cesarean.

The client requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. What does the nurse respond? 1. "The episiotomy goes straight back toward your rectum." 2. "The episiotomy is from your vagina toward the urethra." 3. "The episiotomy is cut diagonally away from your vagina." 4. "The episiotomy extends from your vagina into your rectum."

Answer: 3 Explanation: 3. A mediolateral episiotomy is angled from the vaginal opening toward the buttock. It begins in the midline of the posterior fourchette and extends at a 45-degree angle downward to the right or left.

The postpartum client has chosen to bottle-feed her infant. Nursing actions that aid in lactation suppression include which of the following? 1. Warm showers 2. Pumping milk 3. Ice packs to each breast 4. Avoiding wearing a bra for 5 to 7 days

Answer: 3 Explanation: 3. A nonbreastfeeding mother should use cooling packs for comfort and to decrease the flow of breast milk.

A client calls the urologist's office to receive instructions about semen analysis. What does the nurse instruct the client to do? 1. Avoid sexual intercourse 24 hours prior to obtaining a specimen. 2. Use a latex condom to collect the specimen. 3. Expect that a repeat test might be required. 4. Expect a small sample.

Answer: 3 Explanation: 3. A repeat semen analysis might be required to adequately assess the man's fertility potential.

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? 1. Grunting respirations 2. Nasal flaring 3. Respiratory rate of 40 during sleep 4. Chest retractions

Answer: 3 Explanation: 3. A respiratory rate of 40 during sleep is normal.

A 58-year-old father and a 45-year-old mother gave birth to a baby boy 2 days ago. The nurse assesses a single palmar crease and low-set ears on the newborn. The nurse plans to counsel the couple about which chromosomal abnormality? 1. Trisomy 13 2. Trisomy 18 3. Trisomy 21 4. Trisomy 26

Answer: 3 Explanation: 3. A single palmar crease and low-set ears are characteristics of trisomy 21 (Down syndrome).

The client is at 6 weeks' gestation, and is spotting. The client had an ectopic pregnancy 1 year ago, so the nurse anticipates that the physician will order which intervention? 1. A urine pregnancy test 2. The client to be seen next week for a full examination 3. An antiserumpregnancy test 4. An ultrasound to be done

Answer: 3 Explanation: 3. A β-Subunit radioimmunoassay (RIA) uses an antiserum with specificity for the β-subunit of hCG in blood plasma. This test may not only detect pregnancy but also detect an ectopic pregnancy or trophoblastic disease.

The nurse assessing a pregnant African American woman in the first trimester understands that a cultural practice is which of the following? 1. Use of herbs like dandelion during pregnancy to increase lactation 2. Drinking ginseng tea for faintness 3. Eating clay to supply dietary minerals 4. Consulting a spiritual advisor to ensure a healthy pregnancy and birth

Answer: 3 Explanation: 3. African American pregnant women may be guided by their extended family into common practices such as geophagia, the ingestion of dirt or clay, which is believed to alleviate mineral deficiencies.

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? 1. Call the physician. 2. Administer oxygen. 3. Document the finding. 4. Place the newborn under the radiant warmer.

Answer: 3 Explanation: 3. An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep.

When assisting with a transabdominal sampling, which of the following would the nurse do? 1. Obtain preliminary urinary samples. 2. Have the woman empty her bladder before the test begins. 3. Assist the woman into a supine position on the examining table. 4. Instruct the woman to eat a fat-free meal 2 hours before the scheduled test time.

Answer: 3 Explanation: 3. Clients are placed in a supine position on the table.

The client diagnosed with endometriosis asks the nurse whether there are any long-term health risks associated with this condition. The nurse should include which statement in the client teaching about endometriosis? 1. "There are no other health risks associated with endometriosis." 2. "Pain with intercourse rarely occurs as a long-term problem." 3. "You are at increased risk for ovarian and breast cancer." 4. "Most women with this condition develop severe migraines."

Answer: 3 Explanation: 3. An increased risk for cancer of the ovary and breast is associated with endometriosis.

The nurse is presenting a class of important "dos and don'ts" during pregnancy, including travel considerations. What method of travel does the nurse recommend as most appropriate for a client in her 25th week of pregnancy? 1. Automobile 2. Airplane 3. Train 4. None; this client should not travel

Answer: 3 Explanation: 3. As pregnancy progresses, travel by train is generally recommended for long distances.

The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? 1. "Circumcision should be undertaken to prevent problems in the future." 2. "Circumcision might decrease the child's risk of developing a urinary tract infection." 3. "Circumcision can sometimes cause complications. What questions do you have?" 4. "Circumcision is painful, and should be avoided unless you are Jewish."

Answer: 3 Explanation: 3. Asking this question allows the nurse to determine what the parents' concerns are, then address them specifically.

The nurse is performing a postpartum homecare visit. Which teaching has the highest priority? 1. Teaching or reviewing how to bathe the baby 2. Teaching how to thoroughly childproof the house 3. How many wet diapers the baby should have daily 4. Prevention of plagiocephaly

Answer: 3 Explanation: 3. Assessment of intake, output, weight, and hydration status is imperative. The baby should have at least six diapers that are saturated with clear urine each day by 1 week of age. Wet diapers are an indication of hydration of the newborn. This is the highest priority.

To prevent sudden infant death syndrome (SIDS), the nurse encourages the parents of a term infant to place the infant in which position when the infant is sleeping? 1. On the parents' waterbed 2. Swaddled in the infant swing 3. On the back 4. On the sides

Answer: 3 Explanation: 3. Babies should sleep on their backs every time they are put down for sleep.

A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? 1. Maternal temperature, BP, and pulse 2. Estimation of fetal birth weight 3. Fetal presentation, position, and station 4. Biparietal diameter

Answer: 3 Explanation: 3. Before an amniotomy is performed, the fetus is assessed for presentation, position, station, and FHR.

A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response? 1. "This medication will halt the labor process until the baby is more mature." 2. "This medication will relax the smooth muscles in the infant's lungs so the baby can breathe." 3. "This medication is effective in stimulating lung development in the preterm infant." 4. "This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor."

Answer: 3 Explanation: 3. Betamethasone or dexamethasone is often administered to the woman whose fetus has an immature lung profile to promote fetal lung maturation.

The nurse is supervising care in the emergency department. Which situation most requires an intervention? 1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour 3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports an absence of fetal movement

Answer: 3 Explanation: 3. Bleeding in the third trimester is usually a placenta previa or placental abruption. Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness. Monitor vital signs, particularly blood pressure and pulse, for evidence of developing shock.

When is breastfeeding contraindicated? 1. Infant has hypertension 2. Mother has a history of treated tuberculosis 3. Mother is HIV positive or has AIDS 4. Mother has a history of treated herpes

Answer: 3 Explanation: 3. Breastfeeding is contraindicated when the mother is HIV positive or has AIDS and is counseled against breastfeeding.

A woman has been in labor for 16 hours. Her cervix is dilated to 3 cm and is 80% effaced. The fetal presenting part is not engaged. The nurse would suspect which of the following? 1. Breech malpresentation 2. Fetal demise 3. Cephalopelvic disproportion (CPD) 4. Abruptio placentae

Answer: 3 Explanation: 3. Cephalopelvic disproportion (CPD) prevents the presenting part from becoming engaged.

The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? 1. True labor contractions begin in the back and sweep toward the front. 2. False labor often feels like abdominal tightening, or "balling up." 3. True labor can be diagnosed only if cervical change occurs. 4. False labor contractions do not increase in intensity or duration.

Answer: 3 Explanation: 3. Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilatation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilatation.

The nurse provides a couple with education about the consequences of not treating chlamydia, and knows they understand when they make which statement? 1. "She could become pregnant." 2. "She could have severe vaginal itching." 3. "He could get an infection in the tube that carries the urine out." 4. "It could cause us to develop a rash."

Answer: 3 Explanation: 3. Chlamydia is a major cause of nongonococcal urethritis (NGU) in men.

The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? 1. "This condition is called parametritis." 2. "Gonorrhea is the most common organism that causes this type of infection." 3. "My Beta-strep culture's being positive might have contributed to this problem." 4. "If I had walked more yesterday, this probably wouldn't have happened."

Answer: 3 Explanation: 3. Clinical findings of metritis in the initial 24 to 36 hours postpartum tend to be related to group B streptococcus (GBS).

The nurse is about to tell a client that her Pap smear result was abnormal. Which statement should the nurse include? 1. "The Pap smear is used to diagnose cervical cancer." 2. "A loop electrosurgical excision procedure (LEEP) is needed." 3. "Colposcopy to further examine your cervix is the next step." 4. "Your cervix needs to be treated with cryotherapy."

Answer: 3 Explanation: 3. Colposcopy is an examination of the cervix through a magnifying device.

Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? 1. Enable T or B cells to respond to antigens 2. Repress responses to specific B or T lymphocytes to antigens 3. Kill foreign or virus-infected cells 4. Remove pathogens and cell debris

Answer: 3 Explanation: 3. Cytotoxic activated T cells kill foreign or virus-infected cells.

The nurse is caring for a client diagnosed with endometriosis. Which statement by the client would require a need for perhaps another treatment option? 1. "I am having many hot flashes since I had the Lupron injection." 2. "The pain I experience with intercourse is becoming more severe." 3. "I have vaginal dryness, reduced libido, and my clitoris has become larger since taking danazol. Is this normal?" 4. "I've noticed I have not had my period on a regular basis since being on the GnRH analogs."

Answer: 3 Explanation: 3. Danazol is a testosterone derivative that suppresses ovulation and causes amenorrhea. It is intended for short-term therapy. Because of adverse effects, many clinicians have moved away from danazol to other treatment options.

The postpartum client is about to go home. The nurse includes which subject in the teaching plan? 1. Replacement of fluids 2. Striae 3. Diastasis of the recti muscles 4. REEDA scale

Answer: 3 Explanation: 3. Diastasis recti abdominis can be improved with exercise and abdominal muscle tone can improve significantly best taught when the mother is receptive to instruction during the postpartum assessment.

Which maternal-child client should the nurse see first? 1. Blood type O, Rh-negative 2. Indirect Coombs' test negative 3. Direct Coombs' test positive 4. Blood type B, Rh-positive

Answer: 3 Explanation: 3. Direct Coombs' test is done on the infant's blood to detect antibody-coated Rh-positive RBCs. If the mother's indirect Coombs' test is positive and her Rh-positive infant has a positive direct Coombs' test, Rh immune globulin is not given; in this case, the infant is carefully monitored for hemolytic disease.

The nurse is listening to the fetal heart tones of a client at 37 weeks' gestation while the client is in a supine position. The client states, "I'm getting lightheaded and dizzy." What is the nurse's best action? 1. Assist the client to sit up. 2. Remind the client that she needs to lie still to hear the baby. 3. Help the client turn onto her left side. 4. Check the client's blood pressure.

Answer: 3 Explanation: 3. During pregnancy the enlarging uterus may put pressure on the vena cava when the woman is supine, resulting in supine hypotensive syndrome. This pressure interferes with returning blood flow and produces a marked decrease in blood pressure with accompanying dizziness, pallor, and clamminess, which can be corrected by having the woman lie on her left side.

The nurse educator is lecturing on the changes that take place during puberty. What is a change that girls experience? 1. Elongation of the hips 2. Deepening of the voice 3. Broadening of the hips and budding of breasts 4. Preparation of the uterus for pregnancy

Answer: 3 Explanation: 3. During puberty, girls' hips start to broaden and their breasts begin to form.

The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? 1. "In normal labor, as the uterine contractions become stronger, they usually also become less frequent." 2. "In normal labor, as the uterine contractions become stronger, they usually also become less painful." 3. "In normal labor, as the uterine contractions become stronger, they usually also become longer in duration." 4. "In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration."

Answer: 3 Explanation: 3. During the active and transition phases, contractions become more frequent, are longer in duration, and increase in intensity.

During her first months of pregnancy, a client tells the nurse, "It seems like I have to go to the bathroom every 5 minutes." The nurse explains to the client that this is because of which of the following? 1. The client probably has a urinary tract infection. 2. Bladder capacity increases throughout pregnancy. 3. The growing uterus puts pressure on the bladder. 4. Some women are very sensitive to body function changes.

Answer: 3 Explanation: 3. During the first trimester, the growing uterus puts pressure on the bladder, producing urinary frequency until the second trimester, when the uterus becomes an abdominal organ. Near term, when the presenting part engages in the pelvis, pressure is again exerted on the bladder.

The nurse is preparing a presentation on the menstrual cycle for a group of high school students. Which statement should the nurse include in this presentation? 1. "The menstrual cycle has five distinct phases that occur during the month." 2. "One hormone controls the phases of the menstrual cycle." 3. "The secretory phase occurs when a woman is most fertile." 4. "Menstrual cycle phases vary in order from one woman to another."

Answer: 3 Explanation: 3. During the secretory phase, the vascularity of the entire uterus increases greatly, providing a nourishing bed for implantation.

Which statement, if made by a pregnant client, would indicate that she understands health promotion during pregnancy? 1. "I lie down after eating to relieve heartburn." 2. "I try to limit my fluid intake to 3 or 4 glasses each day." 3. "I elevate my legs while sitting at my desk." 4. "I am avoiding exercise to stay well rested."

Answer: 3 Explanation: 3. Elevating the legs can help decrease lower leg edema.

A client dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure was 120/80 before the procedure and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to increase her BP? 1. Epinephrine 2. Terbutaline 3. Ephedrine 4. Epifoam

Answer: 3 Explanation: 3. Ephedrine is the medication of choice to increase maternal blood pressure.

The client with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The client now has a respiratory rate of 30, pale blue nail beds, a pulse rate of 110, and a temperature of 102.6°F, and is complaining of chest pain. The nurse understands that the client most likely is experiencing which of the following? 1. Pulmonary embolus 2. Pneumococcal pneumonia 3. Pneumonitis 4. Gastroesophageal reflux disease

Answer: 3 Explanation: 3. Even when food and fluids have been withheld, the gastric juice produced during fasting is highly acidic and can produce chemical pneumonitis if aspirated. This pneumonitis is known as Mendelson syndrome. The signs and symptoms are chest pain, respiratory distress, cyanosis, fever, and tachycardia. Women undergoing emergency cesarean births appear to be at considerable risk for adverse events.

The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching? 1. "The fetus's heart rate will vary between 110 and 160." 2. "The heart rate is monitored to see whether the fetus is tolerating labor." 3. "By listening to the heart, we can tell the gender of the fetus." 4. "After listening to the heart rate, you will contact the midwife."

Answer: 3 Explanation: 3. Fetal heart rate is not a predictor of gender.

The nurse is reviewing preconception questionnaires in charts. Which couple are the most likely candidates for preconceptual genetic counseling? 1. Wife is 30 years old, husband is 31 years old 2. Wife and husband are both 29 years old, first baby for husband, wife has a normal 4-year-old 3. Wife's family has a history of hemophilia 4. Single 32-year-old woman is using donor sperm

Answer: 3 Explanation: 3. For families in which the woman is a known or possible carrier of an X-linked disorder, such as hemophilia, the risk of having an affected male fetus is 25%.

The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? 1. "I'll get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I'll bring you an extra so that you can change it when you are ready."

Answer: 3 Explanation: 3. For optimal effect, the ice pack should be applied for 20 to 30 minutes and removed for at least 20 minutes before being reapplied.

The postpartum nurse is performing a homecare visit to a first-time mother on her third day after delivery. She reports that her nipples are becoming sore. What statement indicates that further teaching is needed? 1. "I can apply lanolin cream to help with the nipple pain." 2. "Watching how much areola is visible will help me see whether my baby has a good mouthful of breast or not." 3. "My nipples will heal if I switch to bottle feeding for about 3 days while I pump my breasts." 4. "Rotating breastfeeding positions will allow the sore areas of my nipples to have less friction."

Answer: 3 Explanation: 3. For severe cases, in which the mother is unable to tolerate breastfeeding, the mother will need to pump or hand-express the breast milk until the nipple condition improves. Bottle feeding may not be necessary.

New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? 1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily.

Answer: 3 Explanation: 3. Foreskin will retract normally over time and may take 3 to 5 years.

The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? 1. Tissue Integrity, Impaired 2. Infection, Risk for 3. Gas Exchange, Impaired 4. Family Processes, Dysfunctional

Answer: 3 Explanation: 3. Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production and has the highest priority.

The nurse is providing preoperative teaching to a client for whom a cesarean birth under general anesthesia is scheduled for the next day. Which statement by the client indicates that she requires additional information? 1. "General anesthesia can be accomplished with inhaled gases." 2. "General anesthesia usually involves administering medication into my IV." 3. "General anesthesia will provide good pain relief after the birth." 4. "General anesthesia takes effect faster than an epidural

Answer: 3 Explanation: 3. General anesthesia provides no pain relief after birth, as regional anesthesia does.

A nurse is examining a client with a potential of polycystic ovarian syndrome. The nurse knows that which diagnostic is the most important indicator to support a diagnosis of polycystic ovarian syndrome? 1. Total estrogen level 2. Waist to chest ratio 3. Hyperandrogenism 4. Hypoinsulinemia

Answer: 3 Explanation: 3. Hyperandrogenism, as women with PCOS consistently have elevated serum androgen levels. These elevated androgen levels often lead to clinical manifestations such as hirsutism (excessive hair growth), acne, deepening voice, and increased muscle mass.

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? 1. Increased skin temperature and respirations 2. Blood glucose level of 45 3. Room-temperature IV running 4. Positioned under radiant warmer

Answer: 3 Explanation: 3. IV fluids should be warmed prior to administration and the newborn can be wrapped in a chemically activated warming mattress immediately following birth to decrease the postnatal fall in temperature that normally occurs.

A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do? 1. Go to the nurse's station and immediately call the physician. 2. Run to the delivery room for an emergency birth pack. 3. Stay with the client and ask auxiliary personnel for assistance. 4. Hold back the infant's head forcibly until the physician arrives for the delivery.

Answer: 3 Explanation: 3. If birth is imminent, the nurse must not leave the client alone.

The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? 1. Wrap the diaper tightly. 2. Clean with warm water with each diaper change. 3. Apply gentle pressure to the site with gauze. 4. Apply a new petroleum ointment gauze dressing.

Answer: 3 Explanation: 3. If bleeding does occur, apply light pressure with a sterile gauze pad to stop the bleeding within a short time. If this is not effective, contact the physician immediately or take the newborn to the healthcare provider.

A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn? 1. The client who is discussing how the baby looks like her father 2. The client who is singing softly to her baby 3. The client who continues to touch her baby with only her fingertips 4. The client who picks her baby up when the baby cries

Answer: 3 Explanation: 3. In a progression of touching activities, the mother proceeds from fingertip exploration of the newborn's extremities toward palmar contact with larger body areas and finally to enfolding the infant with the whole hand and arms. If the client continues to touch with only her fingertips, she might not be developing adequate early attachment.

A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what? 1. Menstruation is about to begin. 2. Ovulation will occur soon. 3. Ovulation has occurred. 4. She is pregnant, and will not menstruate.

Answer: 3 Explanation: 3. In some women, ovulation is accompanied by mid-cycle pain, known as mittelschmerz. This pain may be caused by a thick tunica albuginea or by a local peritoneal reaction to the expelling of the follicular contents and body temperature increases about 0.3°C to 0.6°C (0.5°F to 1°F) 24 to 48 hours after the time of ovulation.

What is the increased vascularization causing the softening of the cervix known as? 1. Hegar sign 2. Chadwick sign 3. Goodell sign 4. McDonald sign

Answer: 3 Explanation: 3. Increased vascularization causes the softening of the cervix known as Goodell sign.

The nurse is teaching an early pregnancy class for clients in the first trimester of pregnancy. Which statement by a client requires immediate intervention by the nurse? 1. "When my nausea is bad, I will drink some ginger tea." 2. "The fatigue I am experiencing will improve in the second trimester." 3. "It is normal for my vaginal discharge to be green." 4. "I will urinate less often during the middle of my pregnancy."

Answer: 3 Explanation: 3. Increased whitish vaginal discharge, called leukorrhea, is common in pregnancy. Green discharge is not a normal finding, and indicates a vaginal infection.

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier.

Answer: 3 Explanation: 3. Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented.

Which of the following drugs and drug categories can cause multiple fetal central nervous system (CNS), facial, and cardiovascular anomalies? 1. Category C: Zidovudine 2. Category B: Penicillin 3. Category X: Isotretinoin 4. Category A: Vitamin C

Answer: 3 Explanation: 3. Isotretinoin (Accutane), the acne medication, can cause multiple central nervous system (CNS), facial, and cardiovascular anomalies.

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? 1. Increased pulse 2. Elevated blood pressure 3. Muscle tension 4. Increased respirations

Answer: 3 Explanation: 3. It is important for the woman to relax each part of her body. Be alert for signs of muscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process.

Two hours after an epidural infusion has begun, a client complains of itching on her face and neck. What should the nurse do? 1. Remove the epidural catheter and apply a Band-Aid to the injection site. 2. Offer the client a cool cloth and let her know the itching is temporary. 3. Recognize that this is a common side effect, and follow protocol for administration of Benadryl. 4. Call the anesthesia care provider to re-dose the epidural catheter.

Answer: 3 Explanation: 3. Itching is a side effect of the medication used for an epidural infusion. Benadryl, an antihistamine, can be administered to manage pruritus.

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? 1. Stool characteristics 2. Fluid intake 3. Skin color 4. Bilirubin level

Answer: 3 Explanation: 3. Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Inspection of the skin would be the first step in assessing for jaundice.

Which of the following is the primary carbohydrate in the breastfeeding newborn? 1. Glucose 2. Fructose 3. Lactose 4. Maltose

Answer: 3 Explanation: 3. Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easily digested and well absorbed.

The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement? 1. "I should expect a lighter flow next week." 2. "The flow will increase if I am too active." 3. "My bleeding will remain red for about a month." 4. "I will be able to use a pantiliner in a day or two."

Answer: 3 Explanation: 3. Lochia rubra is dark red in color. It is present for the first 2 to 3 days postpartum. Lochia serosa is a pinkish color and it follows from about the 3rd to the 10th day.

The client vaginally delivers an infant that weighs 4750 g. Moderate shoulder dystocia occurred during the birth. During the initial assessment of this infant, what should the nurse look for? 1. Bell's palsy 2. Bradycardia 3. Erb palsy 4. Petechiae

Answer: 3 Explanation: 3. Macrosomic newborns should be inspected for cephalhematoma, Erb palsy, and fractured clavicles.

Which statement by a pregnant client to the nurse would indicate that the client understood the nurse's teaching? 1. "Because of their birth relationship, fraternal twins are more similar to each other than if they had been born singly." 2. "Identical twins can be the same or different sex." 3. "Congenital abnormalities are more prevalent in identical twins." 4. "Identical twins occur more frequently than fraternal twins."

Answer: 3 Explanation: 3. Monozygotic twinning is considered a random event and occurs in approximately 3 to 4 per 1000 live births. Congenital anomalies are more prevalent and both twins may have the same malformation.

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Begin chest compressions. 2. Begin direct tracheal suctioning. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading.

Answer: 3 Explanation: 3. Most newborns can be effectively resuscitated by bag-and-mask ventilation.

The nurse is creating a poster for pregnant mothers. Which description of fetal development should the nurse include? 1. Four primary germ layers form from the blastocyst. 2. After fertilization, the cells only become larger for several weeks. 3. Most organs are formed by 8 weeks after fertilization. 4. The embryonic stage is from fertilization until 5 months.

Answer: 3 Explanation: 3. Most organs are formed during the embryonic stage, which lasts from the 15th day after fertilization until the end of the 8th week after conception.

After nalbuphine hydrochloride (Nubain) is administered, labor progresses rapidly, and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? 1. Fentanyl (Sublimaze) 2. Butorphanol tartrate (Stadol) 3. Naloxone (Narcan) 4. Pentobarbital (Nembutal)

Answer: 3 Explanation: 3. Narcan is useful for respiratory depression caused by nalbuphine (Nubain). Respiratory depression in the mother or fetus/newborn can be improved by the administration of naloxone (Narcan), which is a specific antagonist for this agent.

Before a newborn and mother are discharged from the hospital, the nurse informs the parents about routine screening tests for newborns. What is a good reason for having the screening tests done? 1. The tests prevent infants from developing phenylketonuria. 2. The tests detect such disorders as hypertension and diabetes. 3. The tests detect disorders that cause physical, intellectual, and developmental complications or death if left undiscovered. 4. The tests prevent sickle-cell anemia, galactosemia, and homocystinuria.

Answer: 3 Explanation: 3. Newborn screening tests use a few drops of the newborn's blood to detect disorders that are often asymptomatic at birth but cause irreversible harm if not detected early. Profound physical, intellectual, and developmental complications and even death can result from many of the conditions for which newborns are screened prior to discharge.

The community nurse is working with a client at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the client would indicate that additional information is needed? 1. "I should call the doctor if I develop a headache or blurred vision." 2. "Lying on my left side as much as possible is good for the baby." 3. "My urine could become darker and smaller in amount each day." 4. "Pain in the top of my abdomen is a sign my condition is worsening."

Answer: 3 Explanation: 3. Oliguria is a complication of preeclampsia. Specific gravity of urine readings over 1.040 correlate with oliguria and proteinuria and should be reported to the physician.

The client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? 1. "You shouldn't work so much at this point in pregnancy." 2. "What you are describing is not commonly experienced in the last weeks." 3. "Your body may be telling you it is going into labor soon." 4. "If the bladder pressure continues, come in to the clinic tomorrow."

Answer: 3 Explanation: 3. One of the premonitory signs of labor is lightening: The fetus begins to settle into the pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing.

The nurse is creating a handout on reproduction for teen clients. Which piece of information should the nurse include in this handout? 1. The fertilized ovum is called a gamete. 2. Prior to fertilization, the sperm are zygotes. 3. Ova survive 12-24 hours in the fallopian tube if not fertilized. 4. Sperm survive in the female reproductive tract up to a week.

Answer: 3 Explanation: 3. Ova are considered fertile for about 12 to 24 hours after ovulation.

The nurse is examining a pregnant woman in the third trimester. What skin changes should the nurse highlight as an alteration for the woman's healthcare provider? 1. Linea nigra 2. Melasma gravidarum 3. Petechiae 4. Vascular spider nevi

Answer: 3 Explanation: 3. Petechiae are pinpoint red or purple spots on the skin. They are seen in hemorrhagic conditions.

The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make? 1. "I have a lot more time to myself than I thought I would have." 2. "My confidence level in my parenting is higher than I anticipated." 3. "I am constantly tired. I feel like I could sleep for a week." 4. "My baby likes everyone, and never fusses when she's held by a stranger."

Answer: 3 Explanation: 3. Physical fatigue often affects adjustments and functions of the new mother. The nurse can also provide information about the fatigue that a new mother experiences, strategies to promote rest and sleep at home, and the impact fatigue can have on a woman's emotions and sense of control.

Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important? 1. Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. 2. Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. 3. Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). 4. Prepare to induce labor after administering a tap water enema.

Answer: 3 Explanation: 3. Pitocin should not administered less than 4 hours after the last Cytotec dose.

The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? 1. Cry is weak and feeble 2. Clitoris and labia minora are prominent 3. Strong sucking reflex 4. Lanugo is plentiful

Answer: 3 Explanation: 3. Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn.

The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client? 1. One visit from a homecare nurse, to take place in 2 days 2. Two visits from a public health nurse over the next month 3. An appointment with a mental health counselor 4. Follow-up with the obstetrician in 6 weeks

Answer: 3 Explanation: 3. Postpartum depression has a high recurrence rate. Women with a history of postpartum psychosis or depression or other risk factors may benefit from a referral to a mental health professional for counseling during pregnancy or postpartum.

A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action? 1. Determine who might be the father of the baby for paternity testing. 2. Ask the client what kind of birthing experience she would like to have. 3. Assess blood pressure and check for proteinuria. 4. Obtain a Social Services referral to discuss adoption.

Answer: 3 Explanation: 3. Preeclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority.

The prenatal client in her third trimester tells the clinic nurse that she works 8 hours a day as a cashier and stands when at work. What response by the nurse is best? 1. "No problem. Your baby will be fine." 2. "Do you get regular breaks for eating?" 3. "Your risk of preterm labor is higher." 4. "Standing might increase ankle swelling."

Answer: 3 Explanation: 3. Pregnant women who are employed in jobs that require prolonged standing (more than 3 hours) do have a higher incidence of preterm birth.

A client with a normal prepregnancy weight asks why she has been told to gain 25-35 pounds during her pregnancy while her underweight friend was told to gain more weight. What should the nurse tell the client the recommended weight gain is during pregnancy? 1. 25-35 pounds, regardless of a client's prepregnant weight 2. More than 25-35 pounds for an overweight woman 3. Up to 40 pounds for an underweight woman 4. The same for a normal weight woman as for an overweight woman

Answer: 3 Explanation: 3. Prepregnant weight determines the recommended weight gain during pregnancy. Underweight women are advised to gain 28-40 pounds.

The nurse has received a phone call from a multigravida who is 21 weeks pregnant and has not felt fetal movement yet. What is the best action for the nurse to take? 1. Reassure the client that this is a normal finding in multigravidas. 2. Suggest that she should feel for movement with her fingertips. 3. Schedule an appointment for her with her physician for that same day. 4. Tell her gently that her fetus is probably dead.

Answer: 3 Explanation: 3. Quickening, or the mother's perception of fetal movement, occurs about 18 to 20 weeks after the LMP in a primigravida (a woman who is pregnant for the first time) but may occur as early as 16 weeks in a multigravida (a woman who has been pregnant more than once).

A nurse teaching a sex education class is asked by a male student, "What exactly happens when my body gets aroused?" The nurse's reply includes which statement? 1. "The vas deferens thickens and expands." 2. "The sympathetic nerves of the penis are stimulated." 3. "The penis elongates, thickens, and stiffens." 4. "The prepuce of the penis elongates."

Answer: 3 Explanation: 3. Sexual stimulation causes the penis to elongate, thicken, and stiffen, a process called erection. The penis becomes erect when its blood vessels become engorged.

The physician has prescribed the medication clomiphene citrate (Clomid) for a client with infertility. What should the nurse's instructions to the woman include? 1. "Have intercourse every day of 1 week, starting 5 days after completion of medication." 2. "This medication is administered intravenously." 3. "Contact the doctor if visual disturbances occur." 4. "A contraindication is kidney disease."

Answer: 3 Explanation: 3. Side effects of clomiphene citrate include visual symptoms such as spots and flashes.

A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect? 1. Nipple soreness 2. Engorgement 3. Mastitis 4. Letdown reflex

Answer: 3 Explanation: 3. Signs of mastitis include late-onset nipple pain, followed by shooting pain between feedings, often radiating to the chest wall. Eventually, the skin of the affected breast may become pink, flaking, and pruritic.

A client from Mexico has just delivered a son, and the nurse offers to assist in putting the baby to breast. Although the client indicated before the birth that she wanted to breastfeed, she is very hesitant, and says she would like to bottle-feed for the first few days. After talking to her, the nurse understands that her primary reason for wanting to delay breastfeeding is based on what cultural belief? 1. Breast milk causes skin rashes. 2. It is harmful to breastfeed immediately. 3. Colostrum is bad for the baby. 4. Thin milk causes diarrhea.

Answer: 3 Explanation: 3. Some Hispanics may delay breastfeeding because they believe colostrum is "bad."

A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? 1. Pain with breastfeeding 2. Number of hours passed since last feeding 3. The newborn's cry 4. Maternal fluid intake

Answer: 3 Explanation: 3. Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience letdown, which can be triggered by hearing, seeing, or even thinking of their baby.

On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following? 1. The taking-hold phase 2. Postpartum hemorrhage 3. The taking-in period 4. Epidural anesthesia

Answer: 3 Explanation: 3. Soon after birth during the taking-in period, the woman tends to be passive and somewhat dependent. She follows suggestions, hesitates about making decisions, and is still rather preoccupied with her needs.

A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful? 1. Talk to the client the entire time. 2. Turn on the television to distract the client. 3. Stand next to the bed with hands on the railing next to the client. 4. Sit silently in the room away from the bed.

Answer: 3 Explanation: 3. Standing next to the bed is supportive without being irritating. The laboring woman fears being alone during labor. The woman's anxiety may be decreased when the nurse remains with her.

An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to do which of the following? 1. Insist that he leave the room for at least the next hour. 2. Tell him he is not being as effective as he was, and that he needs to let someone else take over. 3. Offer to remain with his partner while he takes a break. 4. Suggest that the client's mother might be of more help.

Answer: 3 Explanation: 3. Support persons frequently are reluctant to leave the laboring woman to take care of their own needs. The laboring woman often fears being alone during labor. Even though there is a support person available, the woman's anxiety may be decreased when the nurse remains with her while he takes a break.

The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? 1. Hold the newborn in an upright position. 2. Massage the hands and feet. 3. Swaddle the newborn in a blanket. 4. Make eye contact while talking to the newborn.

Answer: 3 Explanation: 3. Swaddling or bundling the baby increases a sense of security and is a quieting activity.

A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? 1. "Babies have several sleep and alert states. Keep watching and you'll notice them." 2. "You might have noticed that your child was in an alert awake state for an hour after birth." 3. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 4. "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

Answer: 3 Explanation: 3. Teaching the parents how to recognize the two sleep stages helps them tune in to their infant's behavioral states.

The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion? 1. Facial petechiae 2. Large, soft hemorrhoids 3. Tense tissues with severe pain 4. Elevated temperature

Answer: 3 Explanation: 3. Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas.

Which of the following systems provides a uniform format and classification of terminology based on current understanding of cervical disease? 1. Levonorgestrel intrauterine 2. PALM-COEIN 3. Bethesda 4. BSE

Answer: 3 Explanation: 3. The Bethesda System for classifying Pap smears is a standardized method of reporting cytologic Pap smear findings and is the most widely used method in the United States.

During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as which of the following? 1. A negative test 2. A reactive test 3. A nonreactive test 4. An equivocal test

Answer: 3 Explanation: 3. The FHR acceleration must be at least 15 beats per minute above baseline for at least 15 seconds from baseline to baseline. A nonreactive NST is one that lacks sufficient FHR accelerations over a 40-minute period.

If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist? 1. Call a second physician to assist. 2. Prepare for an immediate cesarean delivery. 3. Assist the woman into McRoberts maneuver. 4. Utilize fundal pressure to push the fetus out.

Answer: 3 Explanation: 3. The McRoberts maneuver is thought to change the maternal pelvic angle and therefore reduce the force needed to extract the shoulders, thereby decreasing the incidence of brachial plexus stretching and clavicular fracture.

The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? 1. 2 days 2. 10 days 3. 8 days 4. 14 days

Answer: 3 Explanation: 3. The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborn's physician.

A client has been diagnosed with bacterial vaginosis. The nurse obtains a sexual history from the client, including contraceptive measures, number of sexual partners, and frequency of intercourse. What is the rationale for the questions? 1. Clients can infect their sexual partners. 2. The nurse is required by law to ask the questions. 3. Clients with bacterial vaginosis can become infected with HIV and other sexually transmitted diseases more easily. 4. The laboratory needs a full client history in order to know for which organisms and antibiotic sensitivities it should test.

Answer: 3 Explanation: 3. The change in normal flora increases the woman's susceptibility to other organisms, making the client more vulnerable to sexually transmitted diseases, including HIV.

A woman asks her nurse what she can do before she begins trying to get pregnant to help her baby, as she is prone to anemia. What would the nurse correctly advise her to do? 1. Get pregnant, then start iron supplementation. 2. Add more carbohydrates to her diet. 3. Begin taking folic acid supplements daily. 4. Have a hemoglobin baseline done now so her progress can be followed.

Answer: 3 Explanation: 3. The common anemias of pregnancy are due either to insufficient hemoglobin production related to nutritional deficiency in iron or folic acid during pregnancy. Folic acid deficiency during pregnancy is prevented by a daily supplement of 0.4 mg (400 micrograms) of folate.

The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means which of the following? 1. Fetal lungs are still immature. 2. The fetus has a congenital anomaly. 3. Fetal lungs are mature. 4. The fetus is small for gestational age.

Answer: 3 Explanation: 3. The concentration of lecithin begins to exceed that of sphingomyelin, and at 35 weeks the L/S ratio is 2:1. When at least two times as much lecithin as sphingomyelin is found in the amniotic fluid, RDS is very unlikely.

The nurse has completed a presentation on reproduction. Which statement indicates that the teaching has been successful? 1. "A male is born with all the sperm he will ever produce." 2. "Females create new ova throughout their reproductive life." 3. "Ova separate into two unequally sized cells." 4. "Each primary spermatocyte divides into four haploid cells."

Answer: 3 Explanation: 3. The first meiotic division produces two cells of unequal size with different amounts of cytoplasm but with the same number of chromosomes.

The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? 1. Preterm appropriate for gestational age, symmetrical IUGR 2. Term small for gestational age, symmetrical IUGR 3. Preterm small for gestational age, asymmetrical IUGR 4. Preterm appropriate for gestational age, asymmetrical IUGR

Answer: 3 Explanation: 3. The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR.

The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? 1. The client reports she had this condition after her last pregnancy. 2. The client develops pain and swelling in her left lower leg. 3. The client appears anxious, and describes pressure in her chest. 4. The client becomes upset that she cannot go home yet.

Answer: 3 Explanation: 3. The most common clinical findings of a pulmonary embolism include dyspnea, pleuritic chest pain, cough with or without hemoptysis, cyanosis, tachypnea and tachycardia, panic, syncope, or sudden hypotension and require immediate intervention.

The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? 1. Right-acromion-dorsal-anterior 2. Right-sacrum-transverse 3. Occiput anterior 4. Posterior position

Answer: 3 Explanation: 3. The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally.

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette

Answer: 3 Explanation: 3. The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus drying the newborn is critical.

When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? 1. Decrease the number of minutes the newborn is at the breast per feeding. 2. Decrease the mother's fluid intake. 3. Place absorbent pads in the bra. 4. Administer oxytocin.

Answer: 3 Explanation: 3. The mother can wear nursing pads inside her bra with instructions to change wet pads frequently.

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I can't believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract can move things along at birth." 3. "Incredibly, his stomach capacity was already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days

Answer: 3 Explanation: 3. The newborn's stomach has a capacity of 22 mL to 27 mL by day 3 of life.

Which of the following tests has become a widely accepted method of evaluating fetal status? 1. Contraction stress test (CST) 2. MSAFP test 3. Non-stress test (NST) 4. Nuchal translucency test

Answer: 3 Explanation: 3. The non-stress test (NST) has become a widely accepted method of evaluating fetal status. This test involves using an external electronic fetal monitor to obtain a tracing of the fetal heart rate (FHR) and observation of acceleration of the FHR with fetal movement.

The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? 1. "Your newborn likes to be touched." 2. "Stroking the newborn will help with stimulation." 3. "Visits must be scheduled between feedings." 4. "Your baby loves her pink blanket."

Answer: 3 Explanation: 3. The nurse always should encourage parents to visit and get to know their newborn, even in the NICU. Nurses foster the development of a safe, trusting environment by viewing the parents as essential caregivers, not as visitors or nuisances in the unit.

The nurse should explain to new parents that their infant's position should be changed periodically during the early months of life to prevent which of the following? 1. Muscle contractures 2. Respiratory distress 3. Permanently flattened areas of the skull 4. Esophageal reflux

Answer: 3 Explanation: 3. The nurse can describe plagiocephaly as a flattened area on the head and can recommend that parents alternate their infant's head position between the right and the left side when placing the infant supine for sleep. Placing the infant's head at alternate ends of the crib every few days is helpful as well.

The pregnant client in her second trimester states, "I didn't know my breasts would become so large. How do I find a good bra?" The best answer for the nurse to make would be which of the following? 1. "Avoid cotton fabrics and get an underwire bra; they fit everyone best." 2. "Just buy a bra one cup size bigger than usual, and it will fit." 3. "Look for wide straps and cups big enough for all of your breast tissue." 4. "There isn't much you can do for comfort. Try not wearing a bra at all."

Answer: 3 Explanation: 3. The nurse should instruct the client to get a bra that fits with straps that are wide and do not stretch and a cup that holds all breast tissue comfortably.

The nurse is planning a homecare visit to a mother who just recently delivered. The neighborhood is known to have a significant crime rate. What should the nurse do when planning this visit to facilitate personal safety? 1. Be friendly to all pets encountered on the visit to build client rapport. 2. Wait to find the exact location until arrival in the neighborhood. 3. Put personal possessions in the trunk when leaving the office. 4. Wear flashy jewelry to garner respect.

Answer: 3 Explanation: 3. The nurse should lock personal belongings in the trunk of the car, out of sight, before starting out or before arriving at the home.

The nurse in a prenatal clinic finds that four clients have called with complaints related to their pregnancies. Which call should the nurse return first? 1. Pregnant woman at 7 weeks' gestation reporting nasal stuffiness 2. Pregnant woman at 38 weeks' gestation experiencing rectal itching and hemorrhoids 3. Pregnant woman at 15 weeks' gestation with nausea and vomiting and a 15-pound weight loss 4. Pregnant woman at 32 weeks' gestation treating constipation with prune juice

Answer: 3 Explanation: 3. The nurse should return this call first because this patient is the highest priority. A 15-pound weight loss is not an expected finding. Although some nausea is common, the woman who suffers from extreme nausea coupled with vomiting requires further assessment.

The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following? 1. Increased blood pressure 2. Hypoglycemia 3. Postpartum hemorrhage 4. Postpartum infection

Answer: 3 Explanation: 3. The nurse will assess for postpartum hemorrhage. Overstretching of uterine muscles with conditions such as multiple gestation, polyhydramnios, or a very large baby may set the stage for slower uterine involution.

The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do? 1. Document the findings. 2. Catheterize the client. 3. Massage the uterine fundus until it is firm. 4. Call the physician immediately.

Answer: 3 Explanation: 3. The nurse would massage the uterine fundus until it is firm by keeping one hand in position and stabilizing the lower portion of the uterus. With one hand used to massage the fundus, the nurse would put steady pressure on the top of the now-firm fundus and to see if she was able to express any clots.

The nurse walks in to find the client crying after the physician informed her of her diagnosis of human papilloma virus (HPV). Which statement by the nurse conveys an attitude of acceptance toward the client with a sexually transmitted infection? 1. "Don't worry about it. In a few weeks, with treatment, the lesions will disappear." 2. "You seem upset. I'll get the doctor." 3. "You seem upset. Can I help answer any questions?" 4. "I think you need to see a therapist."

Answer: 3 Explanation: 3. The nurse's attitude of acceptance and matter-of-factness conveys to the client that she is still an acceptable person who happens to have an infection.

The nurse educator describes the uterus and ovaries as being held in place in the pelvic cavity by what structures? 1. Muscles 2. Tendons 3. Ligaments 4. Peritoneum

Answer: 3 Explanation: 3. The ovaries and uterus are held in place in the pelvic cavity by a number of ligaments.

The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal? 1. The head is delivered after eight "pop-offs" during contractions. 2. A cephalohematoma is present on the fetal scalp. 3. The location of the vacuum is apparent on the fetal scalp after birth. 4. Positive pressure is applied by the vacuum extraction during contractions.

Answer: 3 Explanation: 3. The parents need to be informed that the caput (chignon) on the baby's head will disappear within 2 to 3 days.

The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse? 1. Asking the client to void and donning clean gloves 2. Listening to bowel sounds and then asking when her last bowel movement occurred 3. Offering the patient pre-medication 2 hours before the assessment 4. Completing the assessment and explaining the results to the client

Answer: 3 Explanation: 3. The patient should be offered premedication 30-45 minutes before assessing the fundus, especially if the patient has had a cesareansection.

A client is at a physician's office following the end of treatment for breast cancer. The client is not scheduled to receive any more radiation or chemotherapy at this time. With treatment behind her, the client can now look again to the future. Which phase of psychological adjustment is this client experiencing? 1. Shock 2. Reaction 3. Recovery 4. Reorientation

Answer: 3 Explanation: 3. The recovery phase begins during convalescence following the completion of medical treatment.

A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? 1. Latent phase 2. Active phase 3. Transition phase 4. Fourth stage

Answer: 3 Explanation: 3. The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense.

A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor? 1. Active 2. Latent 3. Transition 4. Fourth

Answer: 3 Explanation: 3. The transition phase begins with 8 cm to 10 cm of dilatation, and contractions become more frequent, are longer in duration, and increase in intensity.

A prenatal client asks the nurse how the baby can possibly come out through her vagina, because a vagina is not nearly as big as a baby. How does the nurse best answer this client's question? 1. "The vagina usually tears as it stretches during childbirth." 2. "The vagina is designed to allow a baby come through." 3. "The vagina changes due to pregnancy allow the vagina to stretch more." 4. "The vagina dilates and effaces in labor so the baby can get out."

Answer: 3 Explanation: 3. The walls of the vagina are covered with ridges, or rugae, crisscrossing each other. These rugae allow the vaginal tissues to stretch enough for the fetus to pass through during childbirth.

The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance? 1. "After the ultrasound, my partner and I will decide how to decorate the nursery." 2. "During the ultrasound we will see which of us the baby looks like most." 3. "The ultrasound will show whether there are abnormalities with the baby's spine." 4. "The blood test wasn't run correctly, and now we need to have the sonogram."

Answer: 3 Explanation: 3. Ultrasound is used to detect neural tube defects. An abnormal serum quadruple screen is not the result of a lab error, and can indicate either an open neural tube defect or trisomy 18 or 21.

A client who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain. Laboratory tests reveal a beta-hCG at a lower-than-expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The client is crying and asks what is happening. The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include? 1. "You're feeling dizzy because the pregnancy is compressing your vena cava." 2. "The pain is due to the baby putting pressure on nerves internally." 3. "The baby is in the fallopian tube; the tube has ruptured and is causing bleeding." 4. "This is a minor problem. The doctor will be right back to explain it to you."

Answer: 3 Explanation: 3. The woman who experiences one-sided lower abdominal pain or diffused lower abdominal pain, vasomotor disturbances such as fainting or dizziness, and referred right shoulder pain from blood irritating the subdiaphragmatic phrenic nerve is experiencing an ectopic pregnancy.

The nurse is presenting a prenatal class to a group of women pregnant for the first time who are all over 35 years of age. The nurse knows that the advantage of waiting until later to start a family is which of the following? 1. That the woman will have an easier labor and delivery. 2. That the baby will be at less of a risk for congenital anomalies. 3. That the woman is more likely to be financially secure. 4. That the woman will be more fertile than a younger woman would.

Answer: 3 Explanation: 3. This delay in starting a family allows women to pursue advanced educational degrees and prepare financially for the impact children will have on their lives.

The client in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best? 1. "Lack of menses and breast enlargement are presumptive signs of pregnancy." 2. "The changes you are describing are definitely indicators that you are pregnant." 3. "Lack of menses can be caused by many things. We need to do a pregnancy test." 4. "You're probably not pregnant, but we can check it out if you like."

Answer: 3 Explanation: 3. This is a true statement, and addresses that these changes could be caused by conditions other than pregnancy.

A couple is seeking advice regarding what they can do to increase the chances of becoming pregnant. What recommendation can the nurse give to the couple? 1. The couple could use vaginal lubricants during intercourse. 2. The couple should delay having intercourse until the day of ovulation. 3. The woman should refrain from douching. 4. The woman should be on top during intercourse.

Answer: 3 Explanation: 3. This is the correct answer, as douching can alter sperm mobility.

The nurse educator is discussing human chromosomes with her students, and knows that the teaching has been effective when a student makes which statement? 1. "All humans have 48 chromosomes and 2 sex chromosomes." 2. "Human chromosomes are shaped like a 'Y'." 3. "Humans have 46 chromosomes, 2 of which are the sex chromosomes." 4. "Only certain body cells contain the chromosomes."

Answer: 3 Explanation: 3. This is the correct answer. There are 22 pairs of similar cells and 2 sex chromosomes.

Which statement by a new mother 1 week postpartum indicates maternal role attainment? 1. "I don't think I'll ever know what I'm doing." 2. "This baby feels like a real stranger to me." 3. "It works better for me to undress the baby and to nurse in the chair rather than the bed." 4. "My sister took to mothering in no time. Why can't I?"

Answer: 3 Explanation: 3. This statement indicates a stage of maternal role attainment in which the new mother feels comfortable enough to make her own decisions about parenting.

The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching has been effective? 1. "If the ultrasound is normal, it means my baby has no abnormalities." 2. "The nuchal translucency measurement will diagnose Down syndrome." 3. "I might be able to see who the baby looks like with the ultrasound." 4. "Measuring the length of my cervix will determine whether I will deliver early."

Answer: 3 Explanation: 3. Three-dimensional ultrasound uses algorithms to vary opacity, transparency, and depth to project an image. This allows curved structures such as the fetal face to be viewed.

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Conjugated bilirubin is eliminated in the conjugated state. 2. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. 3. Total bilirubin is the sum of the direct and indirect levels. 4. Hyperbilirubinemia is a decreased total serum bilirubin level.

Answer: 3 Explanation: 3. Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin.

Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? 1. Urge ambulation 2. Apply ice to the leg 3. Elevate the affected limb 4. Massage her calf

Answer: 3 Explanation: 3. Treatment for superficial thrombophlebitis involves application of local heat, elevation of the affected limb, and analgesic agents.

The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? 1. Wearing a tight-fitting bra 2. Limiting breastfeedings 3. Frequent breastfeedings 4. Restricting fluid intake

Answer: 3 Explanation: 3. Treatment of mastitis includes frequent and complete emptying of the breasts.

At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score? 1. 7 2. 8 3. 9 4. 10

Answer: 3 Explanation: 3. Two points each are scored in each of the categories of heart rate, respiratory effort, muscle tone, and reflex irritability. One point is scored in the category of skin color. The total Apgar would be 9.

The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? 1. The client who was overdue and delivered vaginally 2. The client who delivered by scheduled cesarean delivery 3. The client who had oxytocin augmentation of labor 4. The client who delivered vaginally at 36 weeks

Answer: 3 Explanation: 3. Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor.

The client has been found to have vitiligo on her vulva. Which client statement indicates that the client requires additional teaching on this condition? 1. "This can occur in other places on my body." 2. "Vitiligo is only a decrease of pigmentation." 3. "Other serious health conditions are common with vitiligo." 4. "There usually are no other symptoms of this condition."

Answer: 3 Explanation: 3. Vitiligo is an absence of melanin, which results in white patches that are especially noticeable on dark-skinned individuals. It can occur in multiple areas on the body, and has no associated symptoms or health conditions.

) The nurse is teaching a client who has been diagnosed with vulvitis. Which statement by the client indicates that the nurse's instruction has not been effective? 1. "I should stop having sexual intercourse." 2. "Non-deodorized tampons could make this condition recur." 3. "Wearing pantyhose daily will improve the problem." 4. "A different brand of soap might eliminate the irritation."

Answer: 3 Explanation: 3. Vulvitis is inflammation of the vulva. Tight clothing, especially if made of synthetic fibers, can predispose women to the condition. Pantyhose should not be worn.

A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that the client requires more information about VBAC? 1. "I can try a vaginal birth because my uterine incision is a low segment transverse incision." 2. "The vertical scar on my skin doesn't mean that the scar on my uterus goes in the same direction." 3. "There is about a 90% chance of giving birth vaginally after a cesarean." 4. "Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there."

Answer: 3 Explanation: 3. Women whose previous cesarean was performed because of nonrecurring indications have been reported to have approximately a 60% to 80% chance of success with VBAC.

The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? 1. A mother with a poorly balanced diet 2. A mother who is overweight 3. A mother who is HIV positive 4. A mother who has twins

Answer: 3 Explanation: 3. Women with HIV or AIDS are counseled against breastfeeding.

Women with pyelonephritis during pregnancy are at significantly increased risk for which condition? 1. Foul-smelling discharge 2. Ectopic pregnancy 3. Preterm labor 4. A colicky large intestine

Answer: 3 Explanation: 3. Women with pyelonephritis during pregnancy are at significantly increased risk of preterm labor, preterm birth, development of adult respiratory distress syndrome, and septicemia.

The nurse is providing discharge instructions to a client with a diagnosis of vulvovaginal candidiasis (VVC), and knows the client understands when she makes which of the following statements? 1. "I need to apply the miconazole for 10 days." 2. "I need to douche daily." 3. "I need to add yogurt to my diet." 4. "I need to wear nylon panties."

Answer: 3 Explanation: 3. Yogurt helps reestablish normal vaginal flora.

The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "We should avoid holding the baby too much." 2. "Looking directly into the baby's eyes might frighten him." 3. "Talking to the baby is good because he'll recognize our voices." 4. "Holding the baby so we have direct face-to-face contact is good." 5. "We should only touch the baby with our fingertips for the first month."

Answer: 3, 4 Explanation: 3. Attachment behaviors include cuddling, soothing, and calling the baby by name. 4. Attachment behaviors include holding the baby in the en face position.

A nurse is providing a client with instructions regarding breast self-examination (BSE). Which of the following statements by the client would indicate that the teaching has been successful? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I should perform BSE 1 week prior to the start of my period." 2. "When I reach menopause, I will perform BSE every 2 months." 3. "Knowing the density of my breast tissue is important." 4. "I should inspect my breasts while standing with my arms down at my sides." 5. "I should inspect my breasts while in a supine position with my arms at my sides."

Answer: 3, 4 Explanation: 3. The effectiveness of BSE is determined by the woman's ability to perform the procedure correctly, by her knowledge of her own breast tissue, and by the density of her breast tissue. 4. The breasts should be inspected while standing with arms at sides.

Lacerations of the cervix or vagina may be present when bright red vaginal bleeding persists in the presence of a well-contracted uterus. The incidence of lacerations is higher among which of the following childbearing women? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Over the age of 35 2. Have not had epidural block 3. Have had an episiotomy 4. Have had a forceps-assisted or vacuum-assisted birth 5. Nulliparous

Answer: 3, 4 Explanation: 3. The incidence of lacerations is higher among childbearing women who undergo an episiotomy. 4. The incidence of lacerations is higher among childbearing women who undergo forceps-assisted or vacuum-assisted birth.

A client scheduled a laparoscopy. After the procedure, what does the nurse instruct the client to do? 1. Stay on bed rest for 48 hours. 2. Expect to have shoulder and arm pain. 3. Purchase a rectal tube to relieve the gas. 4. Lie on her back to relieve the gas pain after the procedure.

Answer: 4 Explanation: 4. Assuming a supine position may help relieve residual shoulder and chest discomfort caused by any remaining gas.

The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "These questions are asked of all women. It's no big deal." 2. "I'd prefer that your partner ask me all the questions, not you." 3. "A client's preferences for her birth are important for me to understand." 4. "Many women have beliefs about childbearing that affect these choices." 5. "I'm gathering information that the nurses will use after the birth."

Answer: 3, 4 Explanation: 3. The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth. 4. The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth.

A diabetic client goes into labor at 36 weeks' gestation. Provided that tests for fetal lung maturity are successful, the nurse will anticipate which of the following interventions? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Administration of tocolytic therapy 2. Beta-sympathomimetic administration 3. Allowance of labor to progress 4. Hourly blood glucose monitoring 5. Cesarean birth may be indicated if evidence of reassuring fetal status exists

Answer: 3, 4 Explanation: 3. There will be no attempt to stop the labor, as this can compromise the mother and fetus. 4. To reduce incidence of congenital anomalies and other problems in the newborn, the woman should be euglycemic (have normal blood glucose) throughout the pregnancy.

Clinical risk factors for severe hyperbilirubinemia include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. African American ethnicity 2. Female gender 3. Cephalohematoma 4. Bruising 5. Assisted delivery with vacuum or forceps

Answer: 3, 4, 5 Explanation: 3. A clinical risk factor for severe hyperbilirubinemia includes cephalohematoma. 4. A clinical risk factor for severe hyperbilirubinemia includes bruising. 5. A clinical risk factor for severe hyperbilirubinemia includes assisted delivery with vacuum or forceps.

The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Woman at 7 cm, fetus in general flexion 2. Woman at 3 cm, fetus in longitudinal lie 3. Woman at 4 cm, fetus with transverse lie 4. Woman at 6 cm, fetus at -2 station, mild contractions 5. Woman at 5 cm, fetal presenting part is right shoulder

Answer: 3, 4, 5 Explanation: 3. A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. 4. Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. 5. When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part.

A woman is scheduled to have an external version for a breech presentation. The nurse carefully reviews the client's chart for contraindications to this procedure, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Station -2 2. 38 weeks' gestation 3. Abnormal fetal heart rate and tracing 4. Previous cesarean section 5. Rupture of membranes

Answer: 3, 4, 5 Explanation: 3. An abnormal fetal heart rate or tracing would be a contraindication to performing a version. A nonreassuring FHR pattern might indicate that the fetus is already stressed and other action needs to be taken. 4. A previous cesarean is a contraindication for version. 5. Rupture of membranes is a contraindication for version because of insufficient amniotic fluid.

The OB-GYN nurse is assessing a pregnant client, and recognizes genetic amniocentesis will be indicated. The nurse makes this conclusion because the indications for genetic amniocentesis include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Maternal age under 35 2. Fetus with no abnormalities on ultrasound 3. One child with a chromosome abnormality 4. A family history of neural tube defects 5. Both parents with an abnormal chromosome

Answer: 3, 4, 5 Explanation: 3. Couples who have had a child with trisomy 21, 18, or 13 have approximately a 1% risk or their age-related risk, whichever is higher, of a future child having a chromosome abnormality. 4. Family history of neural tube defects is an indication for genetic amniocentesis. 5. If both parents carry an autosomal recessive disease, they have a 25% chance with each pregnancy that the fetus will be affected.

Which couples may benefit from prenatal diagnosis? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Couples including women under the age of 35 2. Couples with an unbalanced translocation 3. Couples with a family history of known or suspected single-gene disorder 4. Couples including women with a teratogenic risk secondary to an exposure or maternal health condition 5. Family history of birth defects and/or intellectual disability

Answer: 3, 4, 5 Explanation: 3. Couples with a family history of known or suspected single-gene disorder (e.g., cystic fibrosis, hemophilia A or B, Duchenne muscular dystrophy) may benefit from prenatal diagnosis. 4. Women with a teratogenic risk secondary to an exposure or maternal health condition (e.g., diabetes, seizure disorder) may benefit from prenatal diagnosis. 5. Family history of birth defects and/or intellectual disability (mental retardation) (e.g., neural tube defects, congenital heart disease, cleft lip and/or palate) may benefit from prenatal diagnosis.

The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? 1. Describe the likely reaction of siblings to the new baby. 2. Discuss adaptation to grandparenthood by her parents. 3. Determine whether father-infant attachment is taking place. 4. Assist the mother in identifying the baby's behavior cues.

Answer: 4 Explanation: 4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment.

An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Skin color: Body blue with pinkish extremities 2. Umbilical cord: two veins and one artery 3. Respiration rate of 30-60 irregular 4. Temperature of above 36.5°C (97.8°F) 5. Sole creases that involve the heel

Answer: 3, 4, 5 Explanation: 3. Normal findings would include a respiration rate of 30-60 irregular. 4. Normal findings would include temperature of above 36.5°C (97.8°F). 5. Normal findings would include sole creases that involve the heel.

The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Our baby will be in an incubator to keep him warm." 2. "Breathing might be harder for our baby because he is early." 3. "The growth of our baby will be faster than if he were term." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days."

Answer: 3, 4, 5 Explanation: 3. Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity. 4. Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to the infant's poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex. 5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine. Preterm infants usually have some urine output during the first 24 hours of life.

True postterm pregnancies are frequently associated with placental changes that cause a decrease in the uterine-placental-fetal circulation. Complications related to alternations in placenta functioning include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased fetal oxygenation 2. Increased placental blood supply 3. Reduced nutritional supply 4. Macrosomia 5. Risk of shoulder dystocia

Answer: 3, 4, 5 Explanation: 3. Reduced nutritional supply is a complication related to alternations in placenta functioning. 4. Macrosomia is a complication related to alternations in placenta functioning. 5. Risk of shoulder dystocia is a complication

The nurse is meeting with a new mother for the first time during a home visit. The client delivered her first child 3 days ago. She had a normal pregnancy and a vaginal delivery. The infant is breastfeeding. Which statements by the mother indicate that she needs more information about the home visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "You are going to check my baby's weight." 2. "You are going to watch me nurse the baby and give me tips." 3. "You are going to teach my mother about the baby." 4. "You are checking for safety issues when my son starts crawling." 5. "You are going to take blood samples from me and my son."

Answer: 3, 4, 5 Explanation: 3. Teaching of family members might occur, but the main purpose of the visit is to assess the infant's physiologic stability. 4. Safety when the infant crawls should be assessed later. 5. Not all home visits require blood samples. If there were no pregnancy or birth complications, there may not be the need to draw blood from either the mother or the child.

What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Drug's potential effect on hormone production 2. Amount of drug excreted into the mother's blood 3. Drug's potential adverse effects to the infant 4. Infant's age and health 5. Mother's need for the medication

Answer: 3, 4, 5 Explanation: 3. The healthcare provider should consider the drug's potential adverse effects to the infant. 4. The healthcare provider should consider the infant's age and health. 5. The healthcare provider should consider the mother's need for the medication

A nurse working with couples undergoing genetic testing recognizes which of the following as nursing responsibilities? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Allowing the family to interact with the genetic counselor without interference 2. Giving information about support groups when asked 3. Identifying families at risk for genetic problems 4. Aiding families in coping with the crisis 5. Ensuring continuity of nursing care to the family

Answer: 3, 4, 5 Explanation: 3. The nurse has a responsibility to identify families at risk for genetic problems. 4. The nurse should aid families in coping. 5. The nurse needs to ensure continuity of care to the family.

Five clients are in active labor in the labor unit. Which women should the nurse monitor carefully for the potential of uterine rupture? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Age 15, in active labor 2. Age 22, with eclampsia 3. Age 25, last delivery by cesarean section 4. Age 32, first baby died during labor 5. Age 27, last delivery 11 months ago

Answer: 3, 5 Explanation: 3. A woman who has had a previous cesarean section is at risk for uterine rupture. 5. A woman who does not have at least 18 months between deliveries is at greater risk for uterine rupture.

The nurse is explaining the difference between meiosis and mitosis. Which statements would be best? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Meiosis is the division of a cell into two exact copies of the original cell. 2. Mitosis is splitting one cell into two, each with half the chromosomes of the original cell. 3. Meiosis is a type of cell division by which gametes, or the sperm and ova, reproduce. 4. Mitosis occurs in only a few cells of the body. 5. Meiotic division leads to cells that halve the original genetic material.

Answer: 3, 5 Explanation: 3. Meiosis is a special type of cell division by which diploid cells give rise to gametes (sperm and ova). 5. Meiosis creates two cells that contain half the genetic material of the parent cell.

The nurse is teaching experienced postpartum nurses about homecare visits. Which statements indicate that teaching was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I should tell the family to put any guns or knives away." 2. "It is best to blend in with the community and not bring attention to myself on visits." 3. "If I encounter a crime in progress, I should leave the area." 4. "Wearing jewelry is a good way to demonstrate my professionalism." 5. "Ignoring my 'gut' feelings might lead to an unsafe situation."

Answer: 3, 5 Explanation: 3. Nurses should avoid entering areas where violence is in progress. In such cases, they should return to the car and contact the appropriate authorities by calling 911. 5. The nurse should terminate the visit if a situation arises that feels unsafe or if the previous requests are not honored.

The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased pulse 2. High blood pressure 3. Tachycardia 4. Bradycardia 5. Capillary filling time greater than 3 seconds

Answer: 3, 5 Explanation: 3. Tachycardia would be a sign of shock. 5. Capillary filling time greater than 3 seconds would be a sign of shock.

The midwife performs a vaginal exam and determines that the fetal head is at a -2 station. What does this indicate to the nurse about the birth? 1. The birth is imminent. 2. The birth is likely to occur in 1-2 hours. 3. The birth will occur later in the shift. 4. The birth is difficult to predict.

Answer: 4 Explanation: 4. A -2 station means that the fetus is 2 cm above the ischial spines. The ischial spines as a landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. With the fetus's head that high in the pelvis, it is difficult to predict when birth will occur.

A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? 1. To recheck the blood sugar in 6 hours 2. To begin an IV of 10% dextrose 3. To feed the baby 1 ounce of formula 4. To document the findings in the chart

Answer: 4 Explanation: 4. A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action.

A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include? 1. The client can douche every other day. 2. Sexual intercourse can be resumed when the client feels up to it. 3. Light housework will provide needed exercise. 4. The baby's mouth should be examined for thrush.

Answer: 4 Explanation: 4. A breastfeeding mother on antibiotics should check her baby's mouth for signs of thrush, which should be reported to the physician.

The nurse is explaining induction of labor to a client. The client asks what the indications for labor induction are. Which of the following should the nurse include when answering the client? 1. Suspected placenta previa 2. Breech presentation 3. Prolapsed umbilical cord 4. Hypertension

Answer: 4 Explanation: 4. A client with hypertension is appropriate for labor induction.

The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response? 1. "We see this from time to time. It's not a big deal." 2. "The gush is an indication that your fundus isn't contracting." 3. "Don't worry. I'll make sure everything is fine." 4. "Blood pooled in the vagina while you were in bed."

Answer: 4 Explanation: 4. A gush of blood when a fundal massage is undertaken may occur because of normal pooling of blood in vagina when the woman lies down to rest or sleep.

The nurse is caring for a pregnant client. The client's husband has come to the prenatal visit. Which question is the best for the nurse to use to assess the father's adaptation to the pregnancy? 1. "What kind of work do you do?" 2. "What furniture have you gotten for the baby?" 3. "How moody has your wife been lately?" 4. "How are you feeling about becoming a father?"

Answer: 4 Explanation: 4. A husband's adaptation to pregnancy includes his feelings about impending fatherhood.

The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? 1. "Call your pediatrician if the baby's temperature is below 98.6°F axillary." 2. "Your baby's stools will change to a greenish color when your milk comes in." 3. "You can wipe away any eye drainage that might form." 4. "Your infant should wet a diaper at least 6 times per day."

Answer: 4 Explanation: 4. A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake.

The nurse is returning phone calls from clients. Which client does the nurse anticipate would not require a serum beta hCG? 1. A client with a risk of ectopic pregnancy 2. A client with spotting during pregnancy 3. A client with previous pelvic inflammatory disease 4. A client with a previous history of twins

Answer: 4 Explanation: 4. A previous history of twins is not a risk factor for ectopic pregnancy. Beta hCG testing is not indicated for this client.

The client has delivered a 4200 g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best? 1. "The episiotomy extended and tore through your rectal mucosa." 2. "The episiotomy extended and tore up near your vaginal mucous membrane." 3. "The episiotomy extended and tore into the muscle layer." 4. "The episiotomy extended and tore through your anal sphincter."

Answer: 4 Explanation: 4. A third degree laceration includes the anal sphincter.

The couple at 12 weeks' gestation has been told that their fetus has sickle cell disease. Which statement by the couple indicates that they are adequately coping? 1. "We knew we were both carriers of sickle cell. We shouldn't have tried to have a baby." 2. "If we had been healthier when we conceived, our baby wouldn't have this disease now." 3. "Taking vitamins before we got pregnant would have prevented this from happening." 4. "The doctor told us there was a 25% chance that our baby would have sickle disease."

Answer: 4 Explanation: 4. A true statement indicates coping. When both parents are carriers of an autosomal recessive disease, there is a 25% risk for each pregnancy that the fetus will be affected.

The nurse explains to a preconception class that if only a small volume of sperm is discharged into the vagina, an insufficient quantity of enzymes might be released when they encounter the ovum. In that case, pregnancy would probably not result, because of which of the following? 1. Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus. 2. The block to polyspermy (cortical reaction) would not occur. 3. The fertilized ovum would be unable to implant in the uterus. 4. Sperm would be unable to penetrate the zona pellucida of the ovum.

Answer: 4 Explanation: 4. About a thousand acrosomes must rupture to clear enough hyaluronic acid for even a single sperm to penetrate the ovum's zona pellucida successfully. If only a small amount of sperm were released, there most likely would be an insufficient quantity of acrosomes to penetrate the zona pellucida of the ovum and allow fertilization.

After inserting prostaglandin gel for cervical ripening, what should the nurse do? 1. Apply an internal fetal monitor. 2. Insert an indwelling catheter. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a supine position with a right hip wedge.

Answer: 4 Explanation: 4. After the gel, intravaginal insert, or tablet is inserted, the woman is instructed to remain lying down with a rolled blanket or hip wedge under her right hip to tip the uterus slightly to the left for the first 30 to 60 minutes to maintain the cervical ripening agent in place.

A client asks the nurse about treatment for human papilloma viral warts. The nurse's response should be based on what knowledge? 1. An antiviral injection cures approximately 50% of all cases. 2. Aggressive treatment is required to cure warts. 3. Warts often spread when an attempt is made to remove them surgically. 4. No single treatment is best for all types of warts or for all clients.

Answer: 4 Explanation: 4. All atypical, pigmented, and persistent warts should be biopsied and treatment instituted promptly.

Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client? 1. 28-year-old with history of rheumatic heart disease 2. 18-year-old with exposure to HIV 3. 20-year-old with a history of preterm labor 4. 35-year-old with a child with spina bifida

Answer: 4 Explanation: 4. Alpha-fetoprotein (AFP) is a fetal protein that is excreted from the fetal yolk sac during the first 6 weeks of pregnancy. AFP levels can be high or low, with each having different implications for the fetus. If the fetus has a neural tube defect (NTD), the AFP levels will be elevated. NTDs can range from anencephaly to spina bifida. With a past history of a child with spina bifida, this client would be strongly encouraged to have the AFP screening.

The nurse teaching a client describes the effect of a vasectomy on fertilization by saying a man who has had a vasectomy becomes functionally sterile because of which of the following? 1. "Sperm are no longer being produced." 2. "Sperm are no longer motile and fertile." 3. "Sperm sit in the testes where they are formed." 4. "Sperm cannot reach the outside of the body."

Answer: 4 Explanation: 4. Although sperm continue to be produced for the next several years, they can no longer reach the outside of the body.

The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? 1. Day of birth 2. First day after birth 3. Second day after birth 4. Third to fourth day after birth

Answer: 4 Explanation: 4. Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would begin breastfeeding the third or fourth day after the birth.

A newborn has been diagnosed with a disorder that occurs through an autosomal recessive inheritance pattern. The parents ask the nurse, "Which of us passed on the gene that caused the disorder?" Which answer should the nurse tell them? 1. The female 2. The male 3. Neither 4. Both

Answer: 4 Explanation: 4. An affected individual can have clinically normal parents, but both parents are generally carriers of the abnormal gene.

The client at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The client's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the client? 1. "Your low iron intake has caused anemia, which leads to the neural tube defect." 2. "You should increase your vitamin C intake to improve your anemia." 3. "You are too picky about food. Your poor diet caused your baby's defect." 4. "You haven't had enough folic acid in your diet. You should take a supplement."

Answer: 4 Explanation: 4. An inadequate intake of folic acid has been associated with neural tube defects (NTDs) (e.g., spina bifida, anencephaly, meningomyelocele) in the fetus or newborn.

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "I should avoid looking directly into the baby's eyes to prevent frightening the baby." 2. "My baby will be very sleepy immediately after birth and should go to the nursery." 3. "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." 4. "Giving the baby his first bath can really give me a chance to get to know him."

Answer: 4 Explanation: 4. Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their baby's behavior and the nurse can observe and point out behaviors.

In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the client is draped for surgery? 1. Maternal temperature 2. Maternal urine output 3. Vaginal exam 4. Fetal heart tones

Answer: 4 Explanation: 4. Ascertain fetal heart rate (FHR) before surgery and during preparation because fetal hypoxia can result from aortocaval compression.

Nurses should educate parents about which of the following AAP recommendations to promote a safe sleep environment and decrease the risk of SIDS and SUID in infants less than 12 months of age? 1. Babies should not be offered a pacifier while falling asleep. 2. Babies should be bottlefed unless contraindicated. 3. Babies should be under many covers when sleeping to keep them warm. 4. Babies should have "tummy time" when they are awake.

Answer: 4 Explanation: 4. Babies should have "tummy time" when they are awake and observed by an adult to prevent positional plagiocephaly and to promote motor development.

Toward the end of the first stage of labor, a pudendal block is administered transvaginally. What will the nurse anticipate the client's care will include? 1. Monitoring for hypotension every 15 minutes 2. Monitoring FHR every 15 minutes 3. Monitoring for bladder distention 4. No additional assessments

Answer: 4 Explanation: 4. Because a pudendal block is done using a local anesthetic, there is no need for additional monitoring of the mother or the fetus.

As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? 1. Cultural background 2. Plans for keeping the infant 3. Support persons 4. Developmental level

Answer: 4 Explanation: 4. Because her cognitive development is incomplete, the younger adolescent may have fewer problem-solving capabilities. The very young woman needs someone to rely on at all times during labor. She may be more childlike and dependent than older teens.

The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the client alone so she can rest. 2. Ask the family to take a coffee-and-snack break. 3. Encourage the client to have an epidural for pain. 4. Reassure the client that she will not be left alone.

Answer: 4 Explanation: 4. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time.

The nurse caring for a postterm newborn would not perform what intervention? 1. Providing warmth 2. Frequently monitoring blood glucose 3. Observing respiratory status 4. Restricting breastfeeding

Answer: 4 Explanation: 4. Breastfeeding is an appropriate means of feeding for the postterm newborn.

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? 1. Apical heart rate of 140 beats per minute 2. Respiratory rate of 40 3. Temperature of 36.5°C 4. Visible, blue discoloration of the skin

Answer: 4 Explanation: 4. Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect.

The nurse is caring for a client in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time? 1. Assess the odor of the amniotic fluid. 2. Perform Leopold maneuvers. 3. Obtain an order for pain medication. 4. Complete a sterile vaginal exam.

Answer: 4 Explanation: 4. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. The nurse would assess for prolapsed cord via vaginal examination.

Which of the following is a sign of dehydration in the newborn? 1. Slow, weak pulse 2. Soft, loose stools 3. Light colored, concentrated urine 4. Depressed fontanelles

Answer: 4 Explanation: 4. Depressed fontanelles are a sign of dehydration in the newborn.

The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action? 1. To massage the fundus vigorously 2. To assess the client's pain level 3. To increase the rate of the IV 4. To assist the client to the bathroom

Answer: 4 Explanation: 4. Emptying the bladder is the top priority.

The nurse is speaking to a community group about the controversy regarding the length of the hospital stay for postpartum clients. Which statement indicates that a participant needs additional information? 1. "As of 1998, there's a law that requires insurance to pay for a 48-hour stay after an uncomplicated birth." 2. "The length of stay was shortened by insurance companies to decrease healthcare costs." 3. "Early discharge became more popular in the 1980s as an alternative to having a home birth." 4. "With current length-of-stay laws, newborns have no problems at home, and get recommended follow-up care."

Answer: 4 Explanation: 4. Even with the current length-of-stay laws, many newborns do not always receive the recommended follow-up care when they go home early. The health and stability of the mother and baby, the mother's ability and confidence regarding self and newborn care, support systems available, and access to follow-up care should form the basis of the decision.

The client with thalassemia intermedia has a hemoglobin level of 9.0. The nurse is preparing an education session for the client. Which statement should the nurse include? 1. "You need to increase your intake of meat and other iron-rich foods." 2. "Your low hemoglobin could put you into preterm labor." 3. "Increasing your vitamin C intake will help your hemoglobin level." 4. "You should not take iron supplements."

Answer: 4 Explanation: 4. Folic acid supplements are indicated for women with thalassemia, but iron supplements are not given.

A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? 1. That a mild analgesic be administered 2. An epidural 3. A local anesthetic block 4. Nonpharmacologic methods of pain relief

Answer: 4 Explanation: 4. For this pattern of labor, nonpharmacologic methods of pain relief should be suggested. These can include back rubs, providing encouragement, and clean linens.

A 26-year-old client is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? 1. A 50g, 1-hour glucose screening test 2. A single fasting glucose level 3. A 100g, 1-hour glucose tolerance test 4. A 100g, 3-hour glucose tolerance test

Answer: 4 Explanation: 4. Gestational diabetes is diagnosed if two or more of the following values are met or exceeded after taking the 100 g, 3-hour OGTT: Fasting: 95 mg/dL; 1 hour: 180 mg/dL; 2 hours: 155 mg/dL; 3 hours: 140 mg/dL.

While doing a prenatal assessment on a woman who has hepatitis B and intends to become pregnant, the nurse explains the impact of the hepatitis B on pregnancy and birth. Which statement does the nurse include in the teaching? 1. "Your baby contracted hepatitis B from you when she was conceived." 2. "Don't worry about your baby during the birth. You're more likely to be affected then by the hepatitis B." 3. "Your baby will be immune to your hepatitis B." 4. "Hepatitis B does not usually affect the course of pregnancy."

Answer: 4 Explanation: 4. Hepatitis B does not usually affect the course of pregnancy.

) A nurse is teaching a middle school health class on the different types of viral hepatitis. Which statement made by a student indicates the need for further teaching? 1. "Both hepatitis A and E are not chronic infections." 2. "Hepatitis A is characterized by symptoms of jaundice, anorexia, nausea, vomiting, malaise, and fever." 3. "Hepatitis B, C, and D have symptoms similar to those of hepatitis A, and can also include arthralgias, arthritis and skin eruptions or rash." 4. "Both hepatitis B and C have an incubation period of 45-160 days."

Answer: 4 Explanation: 4. Hepatitis B has an incubation period of 45-160 days, but hepatitis C has an incubation period of 14-180 days.

A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation? 1. The fetal heart rate decelerates when three contractions occur within a 10-minute period. 2. The fetal heart rate accelerates when contractions last up to 60 seconds. 3. There are more than five fetal movements in a 10-minute period. 4. There are more than three uterine contractions in a 6-minute period.

Answer: 4 Explanation: 4. Hyperstimulation is characterized by contractions that occur more frequently than every 2 minutes or last longer than 90 seconds.

A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Monitor for feeding difficulties. 2. Assess for facial paralysis. 3. Monitor for signs of hyperglycemia. 4. Maintain a warm environment.

Answer: 4 Explanation: 4. Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss.

The postpartum homecare nurse is assessing a new mother, and finds her temperature to be 101.6°F. What is the most important nursing action? 1. Ask the mother how often and how well the baby is nursing. 2. Determine the frequency of the mother's voiding and stooling. 3. Verify how many hours of sleep she is getting per day. 4. Assess the odor and color of the lochia and perineum.

Answer: 4 Explanation: 4. If the lochia is malodorous, or if the perineum is reddened or malodorous, an infection is present that could be causing the fever.

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? 1. Decreased urine output 2. Pulmonary vascular resistance increases 3. Increased PCO2 4. Increased urination

Answer: 4 Explanation: 4. In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination/diuresis may be an early clue that the baby's condition is improving.

The nurse examines the client's placenta and finds that the umbilical cord is inserted at the placental margin. The client comments that the placenta and cord look different than they did for her first two births. The nurse should explain that this variation in placenta and cord is called what? 1. Placenta accreta 2. Circumvallate placenta 3. Succenturiate placenta 4. Battledore placenta

Answer: 4 Explanation: 4. In battledore placenta, the umbilical cord is inserted at or near the placental margin.

The nurse teaching the phases of the menstrual cycle should include the fact that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and extensive vascular changes occur in which phase? 1. Menstrual phase 2. Proliferative phase 3. Secretory phase 4. Ischemic phase

Answer: 4 Explanation: 4. In the ischemic phase, the corpus luteum begins to degenerate, and as a result, both estrogen and progesterone levels fall. Small blood vessels rupture, and the spiral arteries constrict and retract, causing a deficiency of blood in the endometrium, which becomes pale.

A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool blood testing 4. Assessment of hydration status

Answer: 4 Explanation: 4. Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. This increases their risk of dehydration.

The partner of a client at 16 weeks' gestation accompanies her to the clinic. The partner tells the nurse that the baby just doesn't seem real to him, and he is having a hard time relating to his partner's fatigue and food aversions. Which statement would be best for the nurse to make? 1. "If you would concentrate harder, you'd be aware of the reality of this pregnancy." 2. "My husband had no problem with this. What was your childhood like?" 3. "You might need professional psychological counseling. Ask your physician." 4. "Many men feel this way. Feeling the baby move in a few weeks will help make it real to you."

Answer: 4 Explanation: 4. Initially, expectant fathers may have ambivalent feelings.The extent of ambivalence depends on many factors, including the father's relationship with his partner, his previous experience with pregnancy, his age, his economic stability, and whether the pregnancy was planned. The expectant father must first deal with the reality of the pregnancy and then struggle to gain recognition as a parent from his partner, family, friends, coworkers, society-and from his baby as well.

The client is undergoing lab work and ultrasound for a possible diagnosis of polycystic ovarian syndrome (PCOS). Which problem does the nurse expect to find in the client's history? 1. Multiple first-trimester fetal losses 2. Dyspareunia 3. Vulvitis 4. Oligomenorrhea

Answer: 4 Explanation: 4. Irregular menses, ranging from total absence of periods (amenorrhea) to intermittent or infrequent periods (oligomenorrhea) are the hallmarks of PCOS.

The nurse is educating a group of female adolescents regarding sexually transmitted infections. The nurse knows that learning was achieved when an individual states that the most common symptom is which of the following? 1. Menstrual cramps 2. Heavy menstrual periods 3. Flu-like symptoms 4. Usually there are no signs or symptoms

Answer: 4 Explanation: 4. It is common for women to experience no signs or symptoms when they have contracted a sexually transmitted disease.

The nurse working with mothers over 35 having their first baby knows there are some disadvantages. For what disadvantage would the nurse carefully assess in each client? 1. What kind of insurance the client has for maternity care 2. Whether the client is married 3. Whether the client will continue working after the baby arrives 4. Whether the client has any chronic disease that will have to be addressed

Answer: 4 Explanation: 4. It is important for the nurse to question and assess for any chronic illnesses. The risk of pregnancy complications is higher in women over age 35 who have a chronic condition such as hypertension or diabetes, or who are in poor general health.

A woman calls the clinic and tells a nurse that she thinks she might be pregnant. She wants to use a home pregnancy test before going to the clinic, and asks the nurse how to use it correctly. What information should the nurse give? 1. The false-positive rate of these tests is quite high. 2. If the results are negative, the woman should repeat the test in 2 weeks if she has not started her menstrual period. 3. A negative result merely indicates growing trophoblastic tissue and not necessarily a uterine pregnancy. 4. The client should follow up with a healthcare provider after taking the home pregnancy test.

Answer: 4 Explanation: 4. It is important that clients remember that the tests are not always accurate and they should follow up with a healthcare provider.

A woman at 28 weeks' gestation is asked to keep a fetal activity record and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for more than 30 minutes. Which of the following would be the nurse's most appropriate initial comment? 1. "You need to come to the clinic right away for further evaluation." 2. "Have you been smoking?" 3. "When did you eat last?" 4. "Your baby might be asleep."

Answer: 4 Explanation: 4. Lack of fetal activity for 30 minutes typically is insignificant. Movement varies considerably, but most women feel fetal movement at least 10 times in 3 hours.

The nurse has presented a session on pain relief options to a prenatal class. Which statement indicates that additional teaching is needed? 1. "An epidural can be continuous or can be given in one dose." 2. "A spinal is usually used for a cesarean birth." 3. "Pudendal blocks are effective when a vacuum is needed." 4. "Local anesthetics provide good labor pain relief."

Answer: 4 Explanation: 4. Local anesthetics are not used for labor pain relief. They are used prior to episiotomy and for laceration repair.

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? 1. Monitor urine for amount and characteristics. 2. Encourage late feedings to promote intestinal elimination. 3. All infants should be routinely monitored for iron intake. 4. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above.

Answer: 4 Explanation: 4. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above; cold stress results in acidosis.

The client is at 42 weeks' gestation. Which order should the nurse question? 1. Obtain biophysical profile today. 2. Begin nonstress test now. 3. Schedule labor induction for tomorrow. 4. Have the client return to the clinic in 1 week.

Answer: 4 Explanation: 4. Many practitioners use twice-weekly testing providing the amniotic fluid level is normal. One week is too long a period between assessments.

The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client? 1. Encourage the client to vocalize during contractions. 2. Perform vaginal exams only between contractions. 3. Provide a CD of soft music with sounds of nature. 4. Offer to teach the partner how to massage tense muscles.

Answer: 4 Explanation: 4. Massage is helpful for many clients, especially during latent and active labor. Massage can increase relaxation and therefore decrease tension and pain.

The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? 1. Omphalocele 2. Gastroschisis 3. Diaphragmatic hernia 4. Myelomeningocele

Answer: 4 Explanation: 4. Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on abdomen or on side and restrain (to prevent pressure and trauma to sac). Hydrocephalus often is present.

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? 1. Neonatal jaundice 2. Neonatal hypothermia 3. Neonatal hyperthermia 4. Respiratory distress

Answer: 4 Explanation: 4. Nasal flaring and facial grimacing are signs of respiratory distress.

Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? 1. Preeclampsia screening 2. Congenital kidney disease screening 3. Visual screening 4. Hearing screening

Answer: 4 Explanation: 4. Newborn screening tests include hearing screening tests.

The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? 1. "The baby should be in the back seat." 2. "Newborns must be in rear-facing car seats." 3. "We need instruction on how to use the car seat before installing it." 4. "We can bring the baby home from the hospital without a car seat as it is only a short drive home."

Answer: 4 Explanation: 4. Newborns must go home from the birthing unit in a car seat adapted to fit newborns.

Which of the following is common in many non-Western cultures and is on the increase in the United States? 1. Ceremonial rituals and rites 2. Cultural assessment 3. Cultural values 4. Cosleeping

Answer: 4 Explanation: 4. Some parents advocate cosleeping or bed sharing (one or both parents sleeping with their baby or young child). Cosleeping, which is common in many non-Western cultures, is on the increase in the United States.

The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate? 1. Encourage the new mother, saying, "It will happen soon." 2. Instruct the client to eat a low-fiber diet. 3. Decrease fluid intake. 4. Obtain an order for a stool softener.

Answer: 4 Explanation: 4. Obtaining an order for a stool softener is the correct intervention by the third day. In resisting or delaying the bowel movement, the woman may cause increased constipation and more pain when elimination finally occurs.

The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? 1. Select videos on various topics of newborn care. 2. Organize a class that includes first-time mothers only. 3. Have mothers return in 1 week, when they feel more rested. 4. Schedule time for one-to-one teaching in the mother's room.

Answer: 4 Explanation: 4. One-to-one teaching while the nurse is in the mother's room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions.

The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? 1. 3-day-old male who received hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with light, sticky, yellow drainage on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site

Answer: 4 Explanation: 4. Oozing of greenish yellow material, or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication.

The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? 1. "Sleep and alert states cycle throughout the day." 2. "We can best bond with our child during an alert state." 3. "About half of the baby's sleep time is in active sleep." 4. "Babies sleep during the night right from birth."

Answer: 4 Explanation: 4. Over time, the newborn's sleep-wake patterns become diurnal, that is, the newborn sleeps at night and stays awake during the day. Page Ref: 666

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Respiratory rate 60 and irregular in depth and rhythm 2. Pulse rate 145, cardiac murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds

Answer: 4 Explanation: 4. Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention.

The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? 1. The new nurse holds the infant after giving a gavage feeding. 2. The new nurse provides skin-to-skin care. 3. The new nurse provides care when the baby is awake. 4. The new nurse gives the feeding with room-temperature formula.

Answer: 4 Explanation: 4. Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature.

The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? 1. 4 hours 2. 8 hours 3. 12 hours 4. 24 hours

Answer: 4 Explanation: 4. Previously frozen thawed breast milk is good in the refrigerator for 24 hours only.

The client has read that the placenta produces hormones that are vital to the function of the fetus. It is evident that that the client understands the function of the placenta when she states that which hormone is primarily responsible for the maintenance of pregnancy past the 11th week? 1. Human chorionic gonadotropin (hCG) 2. Human placental lactogen (hPL) 3. Estrogen 4. Progesterone

Answer: 4 Explanation: 4. Progesterone is a hormone essential for pregnancy. After the 11th week, the placenta produces enough progesterone and estrogen to maintain pregnancy.

The nurse is presenting a community education session on female hormones. Which statement from a participant indicates the need for further information? 1. "Estrogen is what causes females to look female." 2. "The presence of some hormones causes other to be secreted." 3. "Progesterone is present at the end of the menstrual cycle." 4. "Prostaglandin is responsible for achieving conception."

Answer: 4 Explanation: 4. Prostaglandin is not related to conception. Prostaglandin production increases during follicular maturation and has basic regulatory functions in cells.

) The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior? 1. The client is not attaching to her infant appropriately. 2. The client is not going to be a good mother, and the baby is at risk. 3. The client has no mother present to role-model behaviors. 4. The client is exhibiting normal behavior for her culture.

Answer: 4 Explanation: 4. Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods.

A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? 1. "Formula-feeding gives the baby protection from infections." 2. "Breast milk cannot be stored; it has to be thrown away after pumping." 3. "Breastfeeding is more expensive than formula-feeding." 4. "My baby will have a lower risk of food allergies if I breastfeed."

Answer: 4 Explanation: 4. Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties and plays a role in decreasing the permeability of the small intestine to help prevent large protein molecules from triggering an allergic response.

A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the client needs to be retested for HIV? 1. Hemoglobin of 11 g/dL and a rapid weight gain 2. Elevated blood pressure and ankle edema 3. Shortness of breath and frequent urination 4. Persistent candidiasis

Answer: 4 Explanation: 4. Signs and symptoms of infections include fever, weight loss, fatigue, persistent candidiasis, diarrhea, cough, and skin lesions (Kaposi's sarcoma and hairy leukoplakia in the mouth).

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? 1. "Our baby's heart murmur is from this syndrome." 2. "He might be a fussy baby because of this." 3. "His face looks like it does due to this problem." 4. "Cuddling and rocking will help him stay calm."

Answer: 4 Explanation: 4. The FASD baby is most comfortable in a quiet, minimally stimulating environment.

The nurse teaching a class on the reproductive system is discussing what happens at puberty. Which statement does the nurse make? 1. Boys and girls go through puberty at the same time. 2. Most girls develop breasts and start their menses at about the same time. 3. The nocturnal emissions that adolescent boys have contain a large number of sperm. 4. The onset and progress of puberty varies widely from person to person.

Answer: 4 Explanation: 4. The age at onset and progress of puberty vary widely, physical changes overlap, and the sequence of events can vary from person to person.

When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are what? 1. Both are approximately the same size 2. Both close within 12 months of birth 3. Both are used in labor to identify station 4. Both allow for assessing the status of the newborn after birth

Answer: 4 Explanation: 4. The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth.

The nurse educator is discussing abdominal and vaginal hysterectomy with the students. The nurse explains that the one main disadvantage of a vaginal hysterectomy is which of the following? 1. More blood loss with the surgery 2. Increased pain postoperatively 3. A longer recuperation period 4. Trauma to the bladder

Answer: 4 Explanation: 4. The chance of doing some trauma to the bladder is greater with the vaginal hysterectomy.

The client has just been diagnosed as diabetic. The nurse knows teaching was effective when the client makes which statement? 1. "Ketones in my urine mean that my body is using the glucose appropriately." 2. "I should be urinating frequently and in large amounts to get rid of the extra sugar." 3. "My pancreas is making enough insulin, but my body isn't using it correctly." 4. "I might be hungry frequently because the sugar isn't getting into the tissues the way it should."

Answer: 4 Explanation: 4. The client who understands the disease process is aware that if the body is not getting the glucose it needs, the message of hunger will be sent to the brain.

During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? 1. Turn the client onto her left side. 2. Place the bed in Trendelenburg position. 3. Massage the fundus. 4. Continue to monitor.

Answer: 4 Explanation: 4. The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia.

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? 1. Firm fundus 2. Fundus at the umbilical level 3. Moderate lochia rubra 4. Steady trickle of blood

Answer: 4 Explanation: 4. The continuous seepage of blood is more consistent with cervical or vaginal lacerations. Lacerations should be suspected if the uterus is firm and of expected size and if no clots can be expressed. This finding would indicate a follow-up.

While caring for a client in labor, the nurse notices during a vaginal exam that the fetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be? 1. Flexion, extension, restitution, external rotation, and expulsion 2. Expulsion, external rotation, and restitution 3. Restitution, flexion, external rotation, and expulsion 4. Extension, restitution, external rotation, and expulsion

Answer: 4 Explanation: 4. The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

What is the function of the scrotum? 1. Produce testosterone, the primary male sex hormone 2. Deposit sperm in the female vagina during sexual intercourse so that fertilization of the ovum can occur 3. Provide a reservoir where spermatozoa can survive for a long period 4. Protect the testes and the sperm by maintaining a temperature lower than that of the body

Answer: 4 Explanation: 4. The function of the scrotum is to protect the testes and the sperm by maintaining a temperature lower than that of the body.

A 21-year-old at 12 weeks' gestation with her first baby has known cardiac disease, class III, as a result of childhood rheumatic fever. During a prenatal visit, the nurse reviews the signs of cardiac decompensation with her. The nurse will know that the client understands these signs and symptoms if she states that she would notify her doctor if she had which symptom? 1. "A pulse rate increase of 10 beats per minute" 2. "Breast tenderness" 3. "Mild ankle edema" 4. "A frequent cough"

Answer: 4 Explanation: 4. The heart's signal of its decreased ability to meet the demands of pregnancy includes frequent cough (with or without hemoptysis).

The nurse is preparing a handout for female adolescents on the menstrual cycle. What phase of the cycle occurs if fertilization does not take place? 1. Menstrual 2. Proliferative 3. Secretory 4. Ischemic

Answer: 4 Explanation: 4. The ischemic phase occurs if fertilization does not occur.

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? 1. "Take your newborn to the pediatrician." 2. "There might be a possible food allergy." 3. "Your newborn has diarrhea." 4. "This is a normal occurrence."

Answer: 4 Explanation: 4. The newborn's stools change from meconium (thick, tarry, black) to transitional stools (thinner, brown to green).

A nonpregnant client is diagnosed with bacterial vaginosis (BV). What does the nurse expect to administer? 1. Penicillin G 2 million units IM one time 2. Zithromax 1 mg p.o. b.i.d. for 2 weeks 3. Doxycycline 100 mg p.o. b.i.d. for a week 4. Metronidazole 500 mg p.o. b.i.d. for a week

Answer: 4 Explanation: 4. The nonpregnant woman who is diagnosed with bacterial vaginosis (BV) is treated with metronidazole 500 mg orally twice a day for 7 days.

A client has just been admitted for labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The client wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the client understands which of the following? 1. In order to respect her wishes, no medication will be given. 2. Pain relief will allow a more enjoyable birth experience. 3. The use of medications allows the client to rest and be less fatigued. 4. Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

Answer: 4 Explanation: 4. The nurse can explain to the couple that, although pharmacologic agents do affect the fetus, so do the pain and stress experienced by the laboring mother. If the woman's pain and anxiety are more than she can cope with, the adverse physiologic effects on the fetus may be as great as would occur with the administration of a small amount of an analgesic agent. Once the effects are explained, however, it is still the client's choice whether to receive medication.

The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? 1. "You appear to be Muslim. Do you want your son circumcised?" 2. "Let me explain newborn care here in the United States." 3. "Your baby is a United States citizen. You must be very happy about that." 4. "Could you explain your preferences regarding childrearing?"

Answer: 4 Explanation: 4. The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care.

A client in her third trimester of pregnancy reports frequent leg cramps. What strategy would be most appropriate for the nurse to suggest? 1. Point the toes of the affected leg 2. Increase intake of protein-rich foods 3. Limit activity for several days 4. Flex the foot to stretch the calf

Answer: 4 Explanation: 4. The nurse should advise the client to practice dorsiflexion of feet to stretch affected muscle.

The nurse explains to the client that the obstetric conjugate measurement is important because of which reason? 1. This measurement determines the tilt of the pelvis. 2. This measurement determines the shape of the inlet. 3. The fetus passes under it during birth. 4. The size of this diameter determines whether the fetus can move down into the birth canal so that engagement can occur.

Answer: 4 Explanation: 4. The obstetric conjugate extends from the middle of the sacral promontory to an area approximately 1 cm below the pubic crest. The fetus passes through the obstetric conjugate, and the size of this diameter determines whether the fetus can move down into the birth canal in order for engagement to occur.

The nurse is preparing a handout on the ovarian cycle to a group of middle school girls. Which information should the nurse include? 1. The hormone human chorionic gonadotropin stimulates ovulation. 2. Irregular menstrual cycles have varying lengths of the luteal phase. 3. The ovum leaves its follicle during the follicular phase. 4. There are two phases of the ovarian cycle: luteal and follicular.

Answer: 4 Explanation: 4. The ovarian cycle has two phases: the follicular phase (days 1 to 14) and the luteal phase (days 15 to 28 in a 28-day cycle).

The nurse is working in an outpatient clinic. Which client's indications most warrant fetal monitoring in the third trimester? 1. Gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks 2. Gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior appendectomy 3. Gravida 3, para 2, with a history of gestational diabetes controlled by diet 4. Gravida 2, para 1, 36 weeks, with a history of history of preterm labor or cervical insufficiency

Answer: 4 Explanation: 4. The preterm client with a history of preterm labor or cervical insufficiency needs close monitoring for preterm labor onset.

After delivery, it is determined that there is a placenta accreta. Which intervention should the nurse anticipate? 1. 2 L oxygen by mask 2. Intravenous antibiotics 3. Intravenous oxytocin 4. Hysterectomy

Answer: 4 Explanation: 4. The primary complication of placenta accreta is maternal hemorrhage and failure of the placenta to separate following birth of the infant. An abdominal hysterectomy may be the necessary treatment, depending on the amount and depth of involvement.

During the initial visit with the nurse at the fertility clinic, the client asks what effect cigarette smoking has on the ability to conceive. What is the nurse's best response? 1. "Smoking has no effect." 2. "Only if you smoke more than one pack a day will you experience difficulty." 3. "After your first semen analysis, we will determine whether there will be any difficulty." 4. "Smoking can affect the quantity of sperm."

Answer: 4 Explanation: 4. The quantity and quality of male sperm are affected by cigarette smoking.

The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? 1. The vitamins and minerals in formula are more bioavailable to the infant. 2. There is no cholesterol in breast milk. 3. The only carbohydrate in breast milk is lactose. 4. The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant.

Answer: 4 Explanation: 4. The ratio of whey to casein proteins in breast milk, unlike that in formula, is not static. It changes to meet the nutritional needs of the growing infant.

To assess the healing of the uterus at the placental site, what does the nurse assess? 1. Lab values 2. Blood pressure 3. Uterine size 4. Type, amount, and consistency of lochia

Answer: 4 Explanation: 4. The type, amount, and consistency of lochia determine the state of healing of the placental site, and a progressive color change from bright red at birth to dark red to pink to white or clear should be observed.

Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position? 1. On her right side in the center of the bed with her back curved 2. Lying prone with a pillow under her chest 3. On her left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed

Answer: 4 Explanation: 4. The woman is positioned on her left or right side, at the edge of the bed with the assistance of the nurse, with her legs slightly flexed, or she is asked to sit on the edge of the bed.

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently? 1. A full bladder impedes oxygen flow to the fetus. 2. Frequent voiding prevents bruising of the bladder. 3. Frequent voiding encourages sphincter control. 4. A full bladder can impede fetal descent.

Answer: 4 Explanation: 4. The woman should be encouraged to void because a full bladder can interfere with fetal descent. If the woman is unable to void, catheterization may be necessary.

A client in the emergency department is diagnosed with pelvic inflammatory disease. Before discharge, the nurse will provide the client with some health teaching about which topic? 1. Endometriosis 2. Menopause 3. Ovarian hyperplasia 4. IUD for contraception

Answer: 4 Explanation: 4. The woman who uses an IUD for contraception and has multiple sexual partners needs to understand clearly the risk she faces.

A nurse counsels a couple on sex-linked disorders. Both the man and the woman are carriers of the disorder. They ask the nurse how this disorder will affect any children they might have. What is the nurse's best response? 1. "If you have a daughter, she will not be affected." 2. "Your son will be affected because the father has the disorder." 3. "There is a 25% chance that your son will have the disorder because the mother has the disorder." 4. "There is a 50% chance that your son will be a carrier only."

Answer: 4 Explanation: 4. There is a 50% chance that a carrier mother will pass the normal gene to each of her sons, who will be unaffected.

A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? 1. That the client would be encouraged to ambulate freely 2. That the client would be given aspirin 650 mg by mouth 3. That the client would be given Methergine IM 4. That the client would be placed on bed rest

Answer: 4 Explanation: 4. These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose.

The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? 1. "I'll bring you to your baby and then leave so you can have some privacy." 2. "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." 3. "I am so sorry this has all happened. I know how stressful this can be." 4. "Your baby is working hard to breathe and lying quite still, and has an IV."

Answer: 4 Explanation: 4. This answer is best because it explains what the parents will see in terminology that they will understand. A trusting relationship is essential for collaborative efforts in caring for the infant. The nurse should respond therapeutically to relate to the parents on a one-to-one basis.

The charge nurse has received the shift change report. Which client requires immediate intervention? 1. Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes 2. Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation 3. Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge 4. Woman at 3 cm screaming in fear because her mother died during childbirth

Answer: 4 Explanation: 4. This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority.

The client at 30 weeks' gestation with her first child is upset. She tells the prenatal clinic nurse that she is excited to become a mother, and has been thinking about what kind of parent she will be. But her mother has told her that she doesn't want to be a grandmother because she doesn't feel old enough, while her husband has said that the pregnancy doesn't feel real to him yet, and he will become excited when the baby is actually here. What is the most likely explanation for what is happening within this family? 1. Her husband will not attach with this child and will not be a good father. 2. Her mother is rejecting the role of grandparent, and will not help out. 3. The client is not progressing through the developmental tasks of pregnancy. 4. The family members are adjusting to the role change at their own paces.

Answer: 4 Explanation: 4. This is a true statement. With each pregnancy, routines and family dynamics are altered, requiring readjustment and realignment.

The nurse working with a client describes cellular multiplication and how the zygote moves through the fallopian tube, a movement that takes place via what process? 1. A squeezing motion 2. Pushing from another ovum that has not been fertilized 3. Hormone action 4. A very weak fluid current in the fallopian tube resulting from the beating action of ciliated epithelium

Answer: 4 Explanation: 4. This is correct. There is a very weak fluid current in the fallopian tube resulting from the beating action of the ciliated epithelium that lines the tube.

A 56-year-old client comes into the gynecology clinic with the complaints of constipation and a protrusion from her vagina. What does this client most likely have? 1. A cystocele 2. A prolapsed uterus 3. Polycystic ovarian syndrome 4. A rectocele

Answer: 4 Explanation: 4. This is the correct answer. The client often complains of constipation, and the anterior wall of the rectum protrudes through the vagina.

A nurse working in an infertility clinic should include which information in her discussions with the clients? 1. It is important to know the statistics surrounding couples who never learn why they are infertile. 2. Couples should understand the legal controversy concerning therapeutic insemination. 3. Couples should seek marriage counseling before undergoing fertility treatments. 4. Couples should discuss therapeutic insemination and in vitro fertilization as alternatives.

Answer: 4 Explanation: 4. This is the correct answer. This information should be presented to clients so that they are aware of all the alternatives and can make an informed decision.

The multiparous client at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold maneuvers indicate the fetus is in a transverse lie with a shoulder presentation. Which physician order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Monitor maternal blood pressure every 15 minutes. 4. Alert surgical team of urgent cesarean.

Answer: 4 Explanation: 4. This is the highest priority because vaginal birth is impossible with a transverse lie. Labor should not be allowed to continue, and a cesarean birth is done quickly.

A client has been diagnosed with fallopian tube obstruction and told that her best option for becoming pregnant is with in vitro fertilization. The client asks the nurse about the procedure. What is the nurse's best explanation of this procedure? 1. "In vitro fertilization (IVF) occurs over a full menstrual cycle." 2. "In IVF, a woman's ovaries are stimulated by a combination of egg and sperm donations." 3. "After ovarian stimulation, you will be inseminated with your partner's sperm." 4. "The oocytes are aspirated from the ovaries and fertilized in the laboratory."

Answer: 4 Explanation: 4. This is true. The oocytes are aspirated from the client's ovaries and fertilized in the laboratory.

A 12-year-old girl and her mother are at the doctor's office for a routine check-up for the daughter. The mother tells the nurse that she would like the daughter to have the Gardasil vaccine that is effective against the human papilloma virus. The nurse does some teaching, and knows it has been successful when the mother makes which statement? 1. "The human papilloma virus is spread through casual contact in schools." 2. "Gardasil will protect against all types of the human papilloma virus." 3. "The human papilloma virus affects a million people in the United States." 4. "Gardasil will be given to my daughter in three doses."

Answer: 4 Explanation: 4. This is true. The vaccine is given in three doses.

The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? 1. "What kind of formula would you like to use?" 2. "That idea is folklore. Colostrum is good for the baby." 3. "Now that you are here, you need to feed your baby the right way." 4. "Let's give the baby formula after you breastfeed."

Answer: 4 Explanation: 4. This response attempts to provide a compromise between acknowledging the client's desire to give formula and getting the baby to breast to get colostrum. Nurses should be aware that some immigrant mothers may have this misconception about their colostrum.

The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."

Answer: 4 Explanation: 4. This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby.

The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? 1. "Because I have a midline episiotomy, I should keep my perineum clean." 2. "I can use an ice pack to relieve some the pain from the episiotomy." 3. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 4. "The tear I have through my rectum is unrelated to my episiotomy."

Answer: 4 Explanation: 4. This statement is incorrect. The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum.

How does the nurse assess for Homans' sign? 1. Extending the foot and inquiring about calf pain. 2. Extending the leg and inquiring about foot pain. 3. Flexing the knee and inquiring about thigh pain. 4. Dorsiflexing the foot and inquiring about calf pain.

Answer: 4 Explanation: 4. To assess for thrombophlebitis, the nurse should have the woman stretch her legs out, with the knees slightly flexed and the legs relaxed. The nurse then grasps the foot and dorsiflexes it sharply. If pain is elicited, the nurse notifies the physician/CNM that the woman has a positive Homans' sign. The pain is caused by inflammation of a vessel.

The nurse is presenting a class to newly pregnant families. What form of trauma will the nurse describe as the leading cause of fetal and maternal death? 1. Falls 2. Domestic violence 3. Gun accidents 4. Motor vehicle accidents

Answer: 4 Explanation: 4. Trauma from motor vehicle accidents is the leading cause of fetal and maternal death.

The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching has been effective? 1. "When a client arrives in labor, a urine specimen is obtained by catheter to check for protein and ketones." 2. "When a client arrives in labor, she will be positioned supine to facilitate a normal blood pressure." 3. "When a client arrives in labor, her prenatal record is reviewed for indications of domestic abuse." 4. "When a client arrives in labor, a vaginal exam is performed unless birth appears to be imminent."

Answer: 4 Explanation: 4. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal exam is performed after the vital signs are obtained.

The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue? 1. "If I start to have burning with urination, I need to call the doctor." 2. "Drinking 8 glasses of water each day will help prevent another UTI." 3. "I will remember to wipe from front to back after I move my bowels." 4. "Voiding 2 or 3 times per day will help prevent a recurrence."

Answer: 4 Explanation: 4. Voiding only 2 or 3 times per day is not sufficient to prevent recurrence of a urinary tract infection (UTI). The woman needs to empty her bladder whenever she feels the urge to void at least every 2 to 4 hours while awake.

The client is having fetal heart rate decelerations. An amnioinfusion has been ordered for the client to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? 1. Early decelerations 2. Moderate decelerations 3. Late decelerations 4. Variable decelerations

Answer: 4 Explanation: 4. When cord compression is suspected, amnioinfusion (AI) may be considered. AI helps to prevent the possibility of variable decelerations by increasing the volume of amniotic fluid.

A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant client. When should the first dose of RhoGAM be administered? 1. After the birth of the infant 2. 1 month postpartum 3. During labor 4. At 28 weeks' gestation

Answer: 4 Explanation: 4. When the woman is Rh negative and not sensitized and the father is Rh positive or unknown, Rh immune globulin is given prophylactically at 28 weeks' gestation.

A 21-year-old woman is at 12 weeks' gestation with her first baby. She has cardiac disease, class III, as a result of having had childhood rheumatic fever. Which planned activity would indicate to the nurse that the client needs further teaching? 1. "I will be sure to take a rest period every afternoon." 2. "I would like to take childbirth education classes in my last trimester." 3. "I will have to cancel our trip to Disney World." 4. "I am going to start my classes in water aerobics next week."

Answer: 4 Explanation: 4. With the slightest exertion, the client's heart rate will rise, and she will become symptomatic. Therefore, she should not establish a new exercise program.

Which of the following is a risk factor for urinary retention after childbirth? 1. Multiparity 2. Precipitous labor 3. Unassisted childbirth 4. Not sufficiently recovering from the effects of anesthesia

Answer: 4 Explanation: 4. Women who have not sufficiently recovered from the effects of anesthesia and cannot void spontaneously are at risk for urinary retention after childbirth.

A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for which condition? 1. Erythroblastosis fetalis 2. Diabetes mellitus 3. Abruptio placentae 4. Pregnancy-induced hypertension

Answer: 4 Explanation: 4. Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or preeclampsia-eclampsia).

The client has been diagnosed with hepatitis B. Which statement indicates to the nurse that the client needs more education? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. "This infection could be sexually transmitted." 2. "I might get jaundiced from this illness." 3. "An immunization exists to prevent getting hepatitis B." 4. "I might have gotten this infection from food." 5. "The incubation period is 15-50 days."

Answer: 4, 5 Explanation: 4. Hepatitis B is found in blood and body fluids, and therefore can be sexually transmitted. Hepatitis A and E are foodborne, and transmitted by fecal-oral contamination. 5. The incubation period for hepatitis B is 45-160 days.

The client at 24 weeks' gestation is experiencing painless vaginal bleeding after intercourse. The physician has ordered a transvaginal ultrasound examination. Which statements by the client indicate an understanding of why this exam has been requested? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "This ultrasound will show the baby's gender." 2. "This ultrasound might cause the miscarriage of my baby." 3. "This ultrasound carries a risk of creating a uterine infection." 4. "This ultrasound can determine the location of my placenta." 5. "This ultrasound might detect whether the placenta is detaching prematurely."

Answer: 4, 5 Explanation: 4. Painless bleeding in the second and third trimesters can be a symptom of placenta previa. Transvaginal ultrasound will determine the placental location. 5. Painless bleeding in the second and third trimesters can be a symptom of placenta previa. Transvaginal ultrasound will determine the placental location.

The nurse is caring for a client who was just admitted to rule out ectopic pregnancy. Which orders are the most important for the nurse to perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Report complaints of dizziness or weakness. 5. Have the lab draw blood for B-hCG level every 48 hours.

Answer: 4, 5 Explanation: 4. Reporting complaints of dizziness and weakness is important, as it can indicate hypovolemia from internal bleeding. 5. Having the lab draw blood for B-hCG levels every 48 hours is important, as the level rises much more slowly in ectopic pregnancy than in normal pregnancy.

Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment

Answer: 4, 5 Explanation: 4. The nurse should initiate efforts to block heat loss by evaporation, radiation, convection, and conduction. 5. The infant should be warmed slowly to prevent hypotension and apnea.

A woman who is 40 weeks pregnant calls the labor suite to ask whether she should be evaluated. Which statements by the client indicate she is likely in labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. "The contractions are 5-20 minutes apart." 2. "I had pink discharge on the toilet paper." 3. "I have had cramping for the past 3-4 hours." 4. "The contractions start in my back and then go to my abdomen and are very intense." 5. "The contractions hurt more when I walk."

Answer: 4, 5 Explanation: 4. This is a sign of true labor. The contractions increase in duration and intensity and begin in the back and radiate around to the abdomen. 5. It is a sign of true labor when the client is unable to walk during the contraction.

On assessment, a labor client is noted to have cardiovascular and respiratory collapse and is unresponsive. What should the nurse suspect? 1. An amniotic fluid embolus 2. Placental abruption 3. Placenta accreta 4. Retained placenta

answer 1 Explanation: 1. Cardiovascular and respiratory collapse are symptoms of an amniotic fluid embolus and cor pulmonale.