Midterm Multiple Choice (Chapter 65, 66, 67, 68)

a pt has completed delivery and is in the recovery stage (stage IV) of labor. which is the nurse's role in the care of the neonate at this stage? a. cutting of the umbilical cord when it stops pulsating b. transfer of newborn to the nursery for initial examniation c. suction of the norse and the mouth of the newborn d. assessment of the abgar score at 1 and 5 min

B Rationale: during the fourth stage of labor, the nurse transfers the newborn to the nursery for initial examination. Assessment of the Apgar score at 1 and 5 min, suctioning of nose and mouth, and cutting the umbilical cord when it stops pulsating are done in the 2nd stage of labor.

an attending nurse notices white-or grayish colored bumps on an infant's hard and soft palate. the nurse knows that these are indicative of which condition? a. milia b. epstein pearls c. port-wine stain d. stork bite

B Rationale: epstein pearls are white or grayish colored bumps sometiems found on the infant's hard and soft palate. Stork bite is a mark that often appears on the newborn's eyelids or forehead. port-wine stains are permanent birthmarks, which appear as flat, purple-red areas with sharp borders. milia re pinhead sized white spots resulting fro unopened oil and sweat glands.

the thin, yellowish secretion produced by the breasts for the last half of pregnancy and the first few days postpartum, before milk is secreted, is know as what? a. pimipara b. colostrum c. amniotic fluid d. lochia

B Rationale: colostrum is the thin, yellowish secretion produced by the breasts for the last half of pregnancy and the first few days postpartum, before milk is secreted. it provides vitamins and immune substances that protect the newborn against infection.

A pregnant client with eclampsia is being treated with intravenous magnesium sulfate. What medication should the nurse keep at the bedside in the event toxicity occurs? a. Calcium gluconate b. Potassium chloride c. Protamine sulfate d. Vitamin K

A Rationale: Calcium gluconate is the specific antidote for magnesium sulfate (MgSO4). It is kept at the bedside at all times while the woman receives MgSO4 and is used if toxicity occurs. Potassium chloride is not the antidote for magnesium sulfate. Protamine sulfate is the antidote for heparin and not for magnesium toxicity. Vitamin K is not the antidote for magnesium and is used to assist in blood clotting.

a mother of a newborn baby notices that her baby appears cross-eyed. the nurse reassures her that this is a normal finding and occurs because the neonate's eyes are unable to focus. what other finding should the nurse reassure the client is normal in a newborn? a. flattened ears b. protruding chin c. pointed nose d. flat abdomen

A Rationale: Flattened ears and nose are a normal finding in newborns. The chin is usually receding and not protruding. The nose is not pointed but rather flattened. The abdomen is usually not flat but protruding in newborns.

A client arrives at the clinic stating to the nurse, "I have a positive urine home pregnancy test and a set of twins at home that were born at 32 weeks' gestation." Using the G-P system, how will the nurse document these findings? a. G2 P2 b. G1 P1 c. G2 P1 d. G3 P2

A Rationale: G or gravida is the total number of pregnancies a woman has had, including this one if she is now pregnant. G1 is the woman's first pregnancy. P=Para (birth) is the number of babies born at 20 or more weeks of gestation. Using this system, a woman who gave birth to twins of 32 weeks and is pregnant for the second time is known as G2P2.

a client in her 10th week of pregnancy with suspected pregnancy induced hypertension has sudden development of edema. which of the following symptoms may be signs of pregnancy-induced hypertension. select all that apply. a. visual changes b. epigastric pain c. lordosis d. severe headache e. breast enlargement

A B D Rationale: visual changes, epigastric pain, and severe headache are all signs of pregnancy induced HTN. lordosis and breast enlargement are normal changes during pregnancy

a pt in labor is admitted to a healthcare facility with a prolapsed cord. what actions should the nurse take? select all that apply. a. notify the healthcare provider at once and prepare for resuscitation b. place the woman in the left lateral postition c. performing a sterile vaginal examination d. cover cord with moistened sterile towels e. hold the presenting part away from the cord

A D E Rationale: If the client has a prolapsed cord, the nurse should notify the healthcare provider at once and prepare for resuscitation. If the cord has prolapsed outside the vagina, it is covered with sterile towels and moistened with warm, sterile normal saline. This measure prevents drying and caking of the cord and fetal blood. The nurse must insert a sterile gloved hand into the vagina to hold the fetal presenting part away from the cord. This measure ensures that fetal circulation is not cut off while the woman is prepared for an emergency cesarean delivery. The nurse should place the woman in the Trendelenburg or knee-chest position as ordered, to avoid compression of the cord. The left lateral position is not beneficial. The healthcare provider and not the nurse should perform a sterile vaginal examination.

A pregnant client asks the nurse how she can identify whether she is in labor. which of the following signs is most likely to indicate that labor is approaching? select all that apply. a. strong and regular contractions b. greater difficulty in breathing c. decrease in pedal edema d. increase in urinary frequency e. cervical effacement

A D E Rationale: regular contractions that may become stronger show cervical effacement and dilation, urinary frequency, and increased edema of the legs are the signs that indicate labor is approaching. difficulty in breathing and decrease in pedal edema are not signs of approaching labor.

the decision is made to use an internal monitor for continued monitoring of a pt in labor. the nurse understands the advantages to internal monitoring are what? select all that apply. a. access to the fetal presenting part is necessary b. the fetal electrocardiogram can be monitored c. the procedure is noninvasive and more safe than external monitoring d. the membranes must be ruptured e. precise and high-quality information is available

B E Rationale: internal monitoring is used when more accurate and precise fetal monitoring is needed, including the fetal electrocardiogram. Disadvantages are that the pts membranes must be ruptured and access to the fetal presenting part is necessary. the procedure is invasive and is therefore not convenient and safe as an external monitor.

a newborn is assigned an Apgar score of 3. the nurse undestands that this newborn is: a. in danger and requires further interventions b. in need of emergency resuscitation c. in the best possible condition d. most likely not in need of resuscitation

B Rationale: an Apgar score of 0-3 indicates that the newborn is in need of emergency resuscitation. a score of 10 means that the newborn is in the best possible condition. a score of 7-9 means that the newborn will most likely not need resuscitation. A score of 4 to 6 means that the newborn is in danger.

which complication is more likely in an adolescent pregnancy? a. placenta previa b. hydramnios c. preterm labor d. hypotonic dystocia

C Rationale: Preterm labor is more common in adolescent pregnancy. The older grand multipara may be more likely to have placenta previa, hydramnios, or hypotonic dystocia.

many women do not keep an accurate record of their menstrual periods or may not have regular periods for many different reasons. How is the estimated date of delivery determined? a. using the gestational wheel b. applying Naegele rule c. Estimating fetal age by ultrasound examination d. adding 40 weeks to the date of detection

C Rationale: many women do not keep accurate record of their menstrual periods or may not have regular periods for many different reasons. in these cases, the practitioner determines the estimated date of delivery, also called the estimated date of confinement, based on the size of the uterus during the physical examination and/or an ultrasound estimate of fetal age. Only when you have an accurate date for the last period can the due date for the baby be determined through either a gestational wheel or Naegele rule. Adding 40 weeks to the date of pregnancy detection is incorrect.

a pt has premature rupture of membranes. interventions for this condition are listed below in random order. arrange the interventions according to priority. a. induction of labor b. admission of the client c. ultrasound examination d. amniocentesis

Correct order: B, C, D, A Rationale: The client should be admitted to the healthcare facility when premature rupture of membranes occurs. The client and fetus are then assessed. Ultrasound and amniocentesis will determine fetal maturity. An ultrasound scan should always precede amniocentesis, to determine the location of the placenta and the fetal parts. Labor is induced if the fetus is sufficiently mature.

given below are the steps for application of an external monitor, in random order. Arrange the steps in the correct order. a. attach straps to the Doppler instrument and secure. Place tocodynamometer on the abdomen between umbilicus and top of fundus b. review fetal heart rate and uterine assessment data with client and family. use thorough description of data. c. apply conductive jelly to Doppler instrument and place on client's abdomen until a strong fetal heart rate is heard and a consistent signal is obtained d. elevate head of bed 15 to 30 degrees, or place the client in lateral position. perform Leopold's maneuvers and place two straps under the client.

Correct order: D, C, A, B Rationale: Elevate the head of bed about 15 to 30 degrees, or place the client in lateral position, because elevation and uterine displacement decrease compression of the aorta and vena cava. Perform Leopold maneuvers and place two straps under the client. This locates fetal position and best placement of the Doppler instrument. Apply conductive jelly to the Doppler. This helps to locate the area of maximum fetal heart rate Place the Doppler on the client's abdomen until a strong FHR is heard and a consistent signal is obtained. Attach straps to the Doppler and secure. Place the tocodynamometer on the abdomen between the umbilicus and top of fundus, because this is the contractile portion of the uterus. Care must be taken to avoid placing the tocodynamometer too high on the fundus; otherwise, respirations will be recorded on the monitor. Review FHR and uterine assessment data with client and family. Use thorough descriptions of data. This review promotes understanding of what the client and her family will be observing on the monitor.

when inspecting a newborn, the nurse notices a flat, purple-red area with sharp boarders on the infant's skin. which condition does this indicate? a. Epstein pearls b. Milia spots c. Stork bite d. Port-wine stain

D Rationale: A port-wine stain is a flat, purple-red area with sharp borders. This is a permanent birth-mark. Epstein pearls are white- or grayish-colored bumps that are sometimes found on the hard and soft palate of the mouth. Milia spots are pinhead- sized white spots that appear on the nose and cheeks and are caused by unopened oil and sweat glands. Stork bites are marks that often appear on the newborn's eyelids or forehead.

A newborn received a hepatitis B vaccine after birth. What instructions should be given to the parents by the nurse prior to discharge of the newborn? a. This immunization will last throughout the newborn's life. b. The newborn should be monitored for signs of hepatitis B. c. The newborn will need to be tested for immunity in one month. d. Be sure remaining doses are given according to CDC guidelines.

D Rationale: All newborns receive a first vaccination against hepatitis B shortly after birth. It is important to educate parents about the need for the remaining doses to be given according to the guidelines of the Centers for Disease Control and Prevention. It is safe for the mother to breastfeed, even if the mother is a hepatitis carrier, if the baby has been immunized. It is not necessary for the parents to monitor for signs of hepatitis B. There is no indication for the newborn to have titres drawn for signs of immunity until the complete series of 3 doses is administered.

during an assessment, a nurse instructs a pregnant pt to consult a healthcare provider immediately if she has any vaginal bleeding during the last trimester. such bleeding is usually caused by placenta previa, which is a predisposing factor? a. previous vaginal delivery b. early fertilization of the ovum c. maternal age greater than 40 years d. closely spaced pregnancies

D Rationale: Closely spaced pregnancies are a predisposing factor for placenta previa. Previous cesarean section leaving behind a uterine scar, not a previous vaginal delivery, may predispose to placenta previa. Late, not early, fertilization of the ovum also predisposes to the condition. Maternal age greater than 40 years predisposes to complica-tions such as Down syndrome but not placenta previa.

a woman who has never delivered a live child is known as? a. primipara b. primigravida c. nilligravida d. nullipara

D Rationale: a nullipara is a woman who has never delivered a live child. a nulligravida refers to a woman who has never been pregnant. a primigravida is a woman who is pregnant for the first time. a primipara is the term for a woman who has given birth to one child

a nurse is caring for a pregnant pt with type O blood. with which fetal blood type will the pregnancy and delivery be free of ABO incompatibility? a. O b. A c. B d. AB

O Rationale: if the fetal blood type is O, then there is no chance of ABO incompatibility. ABO incompatibility can arise only if the fetal blood type is A, B, or AB.

a nurse is auscultating for fetal heart tones in a client who is 20 weeks' pregnant. given below are the steps for listening to fetal heart sounds using doppler equipment, in random order. Arrange the steps in the correct order. a. count the fetal heart tones for 15 seconds, and multiply by 4 to get rate per min b. exert a little pressure and place the instrument immediately above the pubic bone c. ask the woman to lie down on her back (supine position) d. slowly rotate the doppler instrument by 360 degrees until you hear the baby's hearbeat

The correct order is: C, B, D, A Rationale: ask the woman to lie down on her back. if she is more than 20wks pregnant, place a small rolled towel under one hip to tilt her slightly to one side. If doppler equipment is being used, apply a small amount of gel to the end of the instrument. Exert a little pressure when placing the instrument immediately above the pubic bone. slowly rotate it 360 degrees until you hear the baby's heartbeat. count the fetal tones for 15 sec and x4 to get rate per minute.

A nurse is assessing a client in the postpartum period. Which is normal a normal assessment in the postpartum period? a. involution of the uterus b. pain behind the knee on flexion of the feet c. voiding of small amounts of urine d. redness, pain, and swelling along a vein

A Rationale: Involution is a normal process in which the client's reproductive organs begin to return to their normal pre-pregnant size. pain behind the knee on flexion of the feet indicates a positive Homans sign and suggests thrombophlebitis. redness, pain, and swelling along the path of a vein may indicate superficial thrombophlebitis. bruising and swelling of the urethra and general los of muscle tone could cause voiding of small amounts of urine

Immediately after the delivery of a newborn, what initial action by the nurse can assist with avoiding heat loss by evaporation? a. Lay the infant on the mother's bare chest or stomach. b. Wipe the infant's head off. c. Place the infant in the radiant warmer. d. Give the infant a warm bath.

A Rationale: Lifting the newborn onto the mother's bare abdomen or chest, perhaps even before the cord is clamped or cut lets the heat of the mother's body transfer to the newborn. Wiping the infant's head off is not the initial action of the nurse. The infant will go into the radiant warmer after the nurse places the child on the mother's abdomen or chest. The bath will not be given until the newborn's temperature is stable.

A parent calls the clinic and states to the nurse, "I changed my newborn's wet diaper and saw a spot of blood on it" What is the best response by the nurse? a. "This is a pseudomenstruation and should disappear within a week" b. "The baby needs to be checked for hormonal disturbance." c. "This finding may indicate a serious female reproductive problem." d. "You must be mistaken, that isn't possible in a newborn."

A Rationale: The genitals of the female infant may be enlarged and have a mucoid, white, or bloodstained discharge. This is called pseudomenstruation. The swelling and discharge will disappear spontaneously within about a week. It is not a hormonal disturbance and does not indicate that there is a disorder in the reproductive system. Nurses should never doubt what clients or parents are telling them.

a nurse is assigned to manage and care for a newborn immediately after delivery. Which should be the immediate action of the nurse? a. establish and maintain airway and respiration b. assist and guide the mother in nursing the baby c. give a warm water tub bath to the infant d. record the weight of the newborn infant

A Rationale: The most important goal for immediate care of the newborn is to establish and maintain the airway and respiration. Assisting the mother to nurse the child and assessing the weight of the child are mandatory; however, these steps can be performed after the physical condition of the child is stabilized. A warm tub bath can be given only after the cord falls off, which is usually 10 to 14 days after birth.

a client is being given preoperative care for cesarean delivery. what is the nurse's role in preoperative care? a. assess for symptoms of fetal distress b. administer general anesthesia to the client c. administer perineal care and oxytocin drugs d. perform external version to turn the fetus

A Rationale: The nurse should assess for symptoms of fetal distress or any unusual discomfort the client might experience. The client is given an epidural (spinal anesthetic), and not a general anesthetic, so that the fetus does not experience any respiratory problems. Administration of perineal care and oxytocic drugs is done during the postoperative period. The birth attendant performs an external version to turn the fetus to a more desirable presentation for a vaginal delivery, not a cesarean delivery.

A client in labor is 100% effaced and fully dilated at 10 cm. What stage of labor does the nurse document the client is experiencing? a. First stage b. Second stage c. Third stage d. Fourth stage

A Rationale: Two distinct cervical changes occur during Stage I: effacement and dilation. Effacement refers to the thinning of the cervix. The cervix, normally long and thick (approximately 1 to 2 cm in length), shortens or thins as a result of contractions. This thinning is measured in percentages. The higher the percentage, the thinner or shorter the cervix. Complete effacement is known as "100% effaced," which describes a cervix that has become almost paper-thin. In dilation, the cervical os (opening), normally held closed in a tight circle, begins to open. Dilation is measured in centimeters from 1 to 10. Complete dilation (10 cm or about 3.9 in) is necessary to allow the uterus to expel the fetus.

a primigravid client opts to formula-feed her infant after birth. what action should the nurse take? a. educate her about formula preparation and storage b. tell her not to formula-feed her infant c. insist to her that only breastfeeding should be done d. tell her that it is a complicated decision and she should reconsider

A Rationale: a woman who opts to formula-feed her infant may have educational needs about formula preparation and storage. The nurse should respect each woman's decision and not impose breastfeeding on her or tell her not to formula feed her infant, nor should she ask her to reconsider her decision.

a nurse is caring for a pt who is 8 mo pregnant. which instruction is the nurse most likely to give her? a. maintain a side-lying position when resting or sleeping to avoid aortocaval compression b. apply lanolin ointment to the nipple and areola to prevent cracking c. do nipple exercises and stimulation on a regular basis d. take a hot water bath or shower daily to maintain hygiene

A Rationale: during last months of pregnancy, nurse should instruct woman to rest and sleep on the side. this position prevents supine hypotension syndrome (aortocaval compression). the body's oil and sweat glands are more active than usual during pregnancy. a daily warm bath and shower is important, rather than a hot bath which may produce hyperthermia. nipple exercises and stimulation should not be done, especially in the 3rd trimester, they can cause uterine contractions and premature labor. lanolin ointment may damage the areola and nipple. it has not been shown to be effective in preventing sore and cracked nipples. lanolin is also a common allergen and may contain insecticide residuals such as DDT.

expulsion of the baby through the vaginal opening occurs at what stage of labor? a. 2 b. 4 c. 1 d. 3

A Rationale: expulsion of the baby through the vaginal opening occurs at stage 2 of labor. stage 1 is when dilation occurs and consists of three phases: latent, active, and transitional. stage 3 is when uterine contractions expel the placenta after the delivery of the newborn. Stage 4 is recovery following expulsion of the placenta.

what nursing care should the nurse focus on during the first stage of labor? a. assessment of client's vitals b. assessment of the placenta c. administration of an oxytocin medication d. assessment of the newborn

A Rationale: first-stage nursing care focuses on assessment of the client's vital signs, contractions, and cervical change, as well as assessment of the fetal well-being. these findings help the birth attendant to determine the fetal condition and the womans progress. assessment of the newborn is done in the second stage. assessment of the placenta and administration of an oxytocic medication is done in the third stage.

during her first trimester, a client experiences many physiologic changes. Which changes should the nurse assure the client are normal for an 8-week pregnancy? a. nausea and vomiting b. dependent edema c. colostrum production d. visual changes

A Rationale: nausea and vomiting are normal during the first trimester of pregnancy. nausea may begin soon after the first missed menstrual period and usually disappears after the third month of pregnancy. Approximately half of all pregnant women experience some nausea or vomiting, usually due to hormonal changes. the woman's breasts begin to produce colostrum by the 14th week. visual changes are not physiologic and may be a sign of pregnancy-induced HTN. dependent edema may occur in the 3rd trimester due to an increase in venous pressure and a decrease in venous return.

a new mother asks the nurse how she should care for her newborn's umbilical cord stump. Which should the nurse include in the educational plan? a. swab the cord stump with alcohol with each diaper change b. cover the stump with the diaper when changing the diapers c. submerge the cord stump in tub water when bathing the newborn d. apply tripple dye to the cut cord and around the umbilicus with each diaper change

A Rationale: the nurse should instruct the mother to swab the cord stump with alcohol with each diaper change. the diaper should not cover the cord stump. the cord stump should be left exposed to the drying effects of the room air. only one application of triple dye is typically required, although some healthcare providers order daily application. in any case, application is not needed with every diaper change. the cord stump should not be submerged in tub water during the newborn's bath until after the cord falls off.

a nurse encounters a pregnant woman in a car in a parking lot who is in active labor and appears ready to deliver her baby. what should the nurse do to assist the woman? a. don gloves, maintain aseptic technique and get medical attention b. take the newborn from the mother and deliver it to the nearest hospital immediately for evaluation c. attempt to delay delivery until an ambulance can come and transport the woman to a hospital d. remember to cut the cord as soon as the baby is born.

A Rationale: the nurse should wear gloves in assisting the delivery and follow aseptic technique as closely as possible. the nurse should not cut the umbilical cord but should clamp it in two places. The nurse should not take the newborn from the mother and deliver it to the nearest hospital but should have the mother told the newborn and put it to her breast.

a nurse is assessing the lochia of a postpartum client. which of the following are abnormal characteristics of lochia? select all that apply. a. large clots are present in lochia b. clear serous discharge occurs for the first 2 days c. lochia does not change color or characteristics d. lochia has a fleshy or metallic odor e. lochia serosa has a slightly earthy odor

A B C Rationale: Large clots, clear serous discharge that occurs for the first 2 days and lochia that does not change color or characteristics are all abnormal findings of lochia. For the first 2 days, lochia is mostly red and bloody, not clear and serous. Lochia should have a fleshy or metallic but never a foul odor. Lochia serosa has a slightly earthy odor, and lochia alba also has an earthy smell.

A client is demonstrating presumptive signs of pregnancy. Which symptoms described by the client should the nurse document as presumptive? Select all that apply. a. Nausea b. Frequent urination c. Breast fullness and tenderness d. Positive urine home pregnancy test e. Basal body temperature elevation

A B C Rationale: he presumptive signs of pregnancy include: amenorrhea, nausea, breast changes, frequent urination, fatigue, quickening, and pigment changes. Probable signs of pregnancy are more objective than the presumptive signs. An obstetrician or midwife may observe them during examination. They are more reliable indicators of pregnancy than the presumptive signs, but still are not proof that a pregnancy exists. Probable signs would include: basal body temperature elevations and positive urine pregnancy test, cervical and uterine changes, and ballottement. Positive signs of pregnancy include ultrasound confirmation, enlargement of the uterus, and fetal heartbeat.

the pt tells the nurse she suspects she may be pregnant. which probable sign may be assessed to determine if the pt is pregnant? select all that apply. a. positive urine pregnancy tests b. basal body temperature elevation c. frequent urination d. enlargement of abdomen e. fetal heartbeat detection

A B D Rationale: basal body temp elevation, positive urine test, and enlarged abdomen are all probable signs of pregnancy. fetal heartbeat detection is a positive sign of pregnancy and frequent urination is a presumptive sign of pregnancy.

A 36-week pregnant client is diagnosed with pregnancy induced hypertension (PIH). What laboratory studies reviewed by the nurse may be an indication that the client is developing HELLP syndrome? Select all that apply. a. Elevated liver enzymes b. A decreased platelet count c. An elevated white blood cell count d. An elevated glucose level e. Low red blood cell count

A B E Rationale: The HELLP syndrome indicates a potentially life-threatening complication of pregnancy-induced hypertension: Hemolysis (destruction of red blood cells, elevated liver enzymes (AST, ALT), low platelet count. An elevated white blood cell count would indicate a potential infection. An elevated glucose level may indicate gestational diabetes.

a pt in her 37th week of gestation reports abdominal pain. which are the signs of approaching labor that the nurse should look for when assessing the pt? select all that apply. a. dilation of cervix b. baxton-hicks contractions c. show or bloody show d. effacement of cervix e. lower abdominal pain

A C D Rationale: involunatry rhythmic uterine contractions that grow stronger, effeacement, and dilation of cervix and show are signs of approaching labor. B-H contractions are usually painless, short, and irregular, and lower abdominal pain is often seen in false labor.

the nurse knows the important goals in caring for the infant immediately after birth include which actions? select all that apply. a. provide a safe environment and routine preventive measures b. teaching the parents regarding cord care and skin care of the newborn c. provide warmth and prevent hypothermia d. establish and maintain airway and respiration e. measure the neonate's weight and height

A C D Rationale: the four goals for immediate care and management of the newborn include establishing and maintaining the infant's airway and respiration, providing warmth and preventing hypothermia, providing safe environment and routine preventive measures, and promoting maternal-infant attachment. this is done to promote health in the newborn and to prevent complications following birth. measurement of the child's height and weight is not necessary as soon as the child is born. this can be done a few hours after birth so that the more urgent and higher priority goals can be attended to first. teaching of cord and skin care is best completed when the mother and baby are stabilized and learning can occur.

the nurse is caring for a family who have experienced the death of their newborn child. what interventions would the nurse include in the care of this family during this time? select all that apply. a. offer to contact a chaplain or counselor if they desire a visit b. allow photos but discourage them, as photos will harbor uncomfortable ememories c. offer mementos such as clothing, lock of hair, identification bracelet d. allow the pt and family to hold the infant as much as they desire e. discuss funeral or cremation options with the family and allow them to share feelings.

A C D E Rationale: the nurse caring for the family experiencing the loss of a newborn will want to offer the support of a chaplain or counselor if the family wants this support. photos are encouraged as are mementos of the baby which acknowledge the baby's existence and also the loss. the mother and family should be encouraged to hold the baby. funeral and cremations should be discussed and the family given the opportunity to share their feelings.

a client in her 19th week of gestation informs the nurse that she has been experiencing light, "fluttery" sensations which she refers to as fetal movements. the nurse knows that this sensation should be documented as which of the following? select all that apply. a. feeling of life b. confirmed pregnancy c. quickening d. morning sickness e. presumptive sign of pregnancy

A C E Rationale: The nurse should document the light, fluttery sensation experienced by the client as a feeling of life, quickening, and a presumptive sign of pregnancy. The first fetal movements that the pregnant woman feels are called quickening. women describe it as a light, fluttery sensation. this feeling of life is considered a presumptive sign of pregnancy, because it cannot be confirmed objectively by anyone other than the woman herself. pregnancy is not confirmed until the existence of a fetus can be proved. nausea or vomiting, caused by hormonal changes in early pregnancy, is called morning sickness.

a new mom is breastfeeding her infant and asks the nurse if she can continue the medications she had earlier been prescribed for an illness. the nurse knows which drugs are generally considered compatible with breastfeeding? select all that apply. a. acetaminophen b. chemotherapy c. phenytoin d. lithium e. codein

A C E Rationale: acetaminophen, codeine, and phenytoin are generally considered compatible with breastfeeding. lithium and chemotherapy agents are particularly dangerous to the nursing newborn and thus are contraindicated in the breastfeeding mother.

preparing the pt to be discharged, the nurse is asked to reinforce with the pt the importance of observing her lochia and informing the healthcare provider if any abnormalities are observed. the nurse will teach the pt which are reasons to call the healthcare provider? select all that apply. a. lochia that does not change in amount 10 days pp b. lochia that smells like blood for up to 2 days PP c. lochia that smells earthy and starts about 10 days PP d. lochia that remains bright red for 6 days PP e. lochia that has a foul odor on day 4 PP

A D E Rationale: Lochia continues for up to 4 wks following delivery. Lochia rubra is seen during the first 2 days and is bright red and smells like blood. Lochia serosa has a pink or brown tinge and has an earthy odor for up to 7 days. lochia alba will be yellow or white, will have an earthy odor and will considerably decrese in amountws. it is abnormal for lochia to have a foul odor at any time, to include bright red bleeding after delivery, or not to decrease in amount 10 days after delivery. Any of these is an indication of a problem.

a pregnant client is excited that she is beginning to feel her baby move within her. how would the nurse document this information? a. amenorrhea b. lactation c. lordosis d. quickening

D Rationale: the first fetal movements that the pregnant woman feels are called quickening and usually occur between 18 and 20 weeks of gestation. amenorrhea is the absence of menstruation and is one of the first indications of pregnancy. lactation is the production of breast milk in preparation for breastfeeding. lordosis is the inward curve of the lower back, which becomes exaggerated during pregnancy.

a nurse is assessing the progress of labor of a client. which station indicates that the fetus is "floating"? a. station + 5 b. station 0 c. station -5 d. station -1

C Rationale: A station of 25 is considered "floating." The station at which the fetus is fully engaged is called station 0; that is, the widest part of the presenting part of the fetus has lodged in the pel-vic inlet, and the lowest part of the fetal skull is at the level of the mother's ischial spines. A station of 1 5 means that the fetal head is at the vaginal opening. Station 21 is 1 cm above the ischial spines.

a mother has just finished bottle-feeding her otherwise healthy baby. the baby is still crying and is believed to have swallowed air from the bottle. what step should the nurse instruct the mother to take? a. gibe gentle but firm pressure on the abdomen b. hold the baby, rock, and pat lightly on the back c. give a little water so that the air settles down d. eliminate milk from the diet for 2 weeks

B Rationale: If the baby has swallowed air from the bottle, the mother should hold the baby, rock him, and pat him lightly on the back. This helps the baby to burp out the air. Firm pressure on the abdomen is unnecessary and may irritate the baby further. The air does not settle down on giving water to the baby. Elimination of milk from the diet of the breastfeeding mother is done when cow's milk causes colic and not when the baby has swallowed air from the bottle.

a 30-year old client has missed her menstrual period and is eager to know if she is pregnant. Which sign ensures that the client is pregnant? a. positive home pregnancy test b. goodell sign c. hearing a fetal heartbeat d. braxton hicks contractions

C Rationale: visualizing the fetus by ultrasound, palpating for fetal movements, and hearing a fetal heartbeat are signs that ensure that the client is pregnant. a positive home pregnancy test, softening of the cervix (Goodell sign), and Braxton Hicks contractions are the probably signs of pregnancy; they do not make the diagnosis of pregnancy a certainty

The nurse is planning the discharge of a client at 32 weeks' gestation with placenta previa. What is important for the nurse to discuss with the client before discharge? a. The client will have to return every 2 weeks to have a vaginal examination. b. The client must remain on strict bed rest at all times. c. The client will have to have a blood transfusion every week. d. The client may not be able to have any more children after this.

B Rationale: If the fetus is under 36 weeks' gestation, the mother is put on strict bed rest either in the healthcare facility or at home. If no bleeding occurs, ultrasound scanning may be done every 2 to 3 weeks along with nonstress testing and biophysical profile. If bleeding is found, a cesarean delivery is anticipated. Vaginal examination is contraindicated and should not be performed because it may cause bleeding. A blood transfusion weekly is not necessary and transfusion would only be used in the case of hemorrhage. There is no indication that another pregnancy cannot occur after placenta previa.

The nurse is assisting with the care of a newborn after delivery. The newborn has an Apgar score of 10 at 1 minute and 5 minutes. What action does the nurse prepare for? a. The newborn is in danger and should be closely monitored. b. No action is required since the baby is in the best possible condition. c. The newborn requires immediate resuscitation measures. d. The newborn requires tactile stimulation.

B Rationale: The Apgar score assists the care providers in determining interventions that may be required. If the total score is 10, the newborn is in the best possible condition. If the score is 7 to 9, the newborn usually does not need resuscitation, if the score is 4 to 6, the newborn is in danger, and if the score is 0 to 3, the newborn needs emergency resuscitation.

A client who is 36 weeks' gestation calls the clinic and states, "I'm not sure if I'm really in labor or if it is false labor." What is the best response by the nurse? a. "It is too early for the baby to be born, go to bed and put your feet up." b. "Change your activity and walk around the house. If it is false labor, you will feel relief. c. "I am sure that it is true labor because it is so close to the due date so it is advisable that you come in to the birthing center." d. "True labor contractions are usually painless, short, and irregular."

B Rationale: Women may sometimes mistake false labor contractions for true labor. They may experience false labor anytime in the last trimester, but more often during the final 2 or 3 weeks of pregnancy. A change in activity, such as walking, may provide the woman some relief. False labor contractions are painless, short, and irregular. If it is true labor, the client would be instructed to come to the birthing center at 36 weeks and not go to bed and put the feet up.

a fertilized ovum is known as? a. chorion b. zygote c. fetus d. embryo

B Rationale: a fertilized ovum is known as a zygote and is the beginning of potential individual human development. the developing human organism is known as an embryo from the time it implants on the uterine wall until the eith week after inception and as a fetus from the beginning of the ninth week after fertilization through birth. the chorion is the outermost cell layer that surrounds the embryo and fluid cavity.

prolonged, painful labor that does not result in effective cervical dilation or effacement is known as: a. eclampsia b. dystocia c. hyperemesis gravidarum d. ectopic pregnancy

B Rationale: dystocia is prolonged, painful labor that does not result in effective cervical dilation or effacement. ectopic pregnancy is a condition in which implantation of the embryo occurs outside the uterus. eclampsia is a serious stage of pregnancy-induced HTN and is characterized by generalized tonic-clonic seizures, very rapid pulse, and very high blood pressure. hyperemesis gravidarum is pernicious vomiting among pregnant women that is much more severe than normal morning sickness.

at a preconceptional visit a client whose husband's family has a history of a genetic defect says she is planning to have a baby. What should the nurse's response be? a. reassure her that it is not a cause of concern b. refer the couple for genetic testing and counseling c. tell her that her husband's family is unrelated to her pregnancy d. tell her that it is unadvisable to have a baby

B Rationale: if the client or her partner has a family history of genetic problems, referral for genetic counseling and testing should be given to the couple. it is a cause for concern, because it may affect her pregnancy and the baby. The nurse is in no position to advise the client against having a baby, because this can be decided only after genetic counseling and testing.

the nurse is competing the birth information in the client's health record. which is the most critical piece of information to record? a. identifying marks b. the date and time of the newborn's birth c. vitamin K administration d. mother's Rh status

B Rationale: in all cases, the mother's full name and the date and time of the newborn's birth are critical importance and should be carefully documented. Other, less critical information to record includes the newborn's sex, condition, type of delivery, identifying marks, care of the eyes, vitamin K administration, and the mother's Rh status.

which term is used to compare the position of the fetal spinal cord to that of the woman? a. presentation b. lie c. station d. position

B Rationale: lie is a term used to compare the position of the fetal spinal cord to that of the woman. presentation refers to the body part of the fetus that lies closest to the pelvis and will enter the birth canal first. station refers to the descent level fo the fetal presenting part into the birth canal. position refers to the relationship between standardized points on the presenting part of the fetus and a designated point on one of four quadrants of the woman's pelvis.

a pt who is considering becoming pregnant asks the nurse about the safety of sports during pregnancy. the nurse would include which in the list of safe sports to participate in while pregnant? a. basketball b. tennis c. football d. gymnastics

B Rationale: racquet sports such as tennis, racquetball, and squash are safe in pregnancy, but the pt should avoid heat stress and decrease intensity as pregnancy progresses. basketball and gymnastics are sports involving potential joint or ligament damage, and football is a contact sport and therefore not advisable during pregnancy.

the nurse is observing a newborn for signs of respiratory distress. which is a normal finding in a newborn's respiratory status? a. marked intercostal retraction b. synchronized respirations c. lag on respirations d. marked nares dilation

B Rationale: synchronized resps are a normal finding (sore of 0) in the Silverman-Andersen index of neonatal respiratory distress. A lag on respirations (score of 1), marked intercostal retraction (score of 1), and marked nares dilation (score of 2) are all abnormal findings.

a nurse is assessing a client to whom oxytocin is being given for labor augmentation. In which situation should the nurse immediately report the observation of contractions? a. if the contractions are rhythmic and becoming stronger b. if the contractions come more often than every 2 minutes c. if the uterine contractions are causing pain d. if each contraction ilasts less than 90 sec

B Rationale: the nurse reports immediately if contractions come more often than every 2 minutes or if each contraction lasts 90 seconds or longer. in these cases, there is not enough relaxation time for the fetus to be well oxygenated. this is event is rare during normal labor but must be carefully watched for when oxytocin is used for labor augmentation or induction. Rhythmic contractions becoming stronger or contractions causing pain are normal and not cause of concern. contractions lasting less than 90 sec are normal.

which organ has a rich blood supply that supplies the developing organism with food and oxygen while also carrying away waster for excretion by the mother? a. uterus b. palcenta c. morula d. ovary

B Rationale: the placenta is an organ with a rich blood supply that supplies the developing organism with food and oxygen, carries waste away for excretion by the mother, slows the maternal immune response so that the mother's body does not reject the fetal tissue, and produces hormones that help maintain the pregnancy. the uterus is the cavity in the abdominal region within which the embryo and fetus develop, along with the placenta. the ovary is the organ that produces the ova. a morula is a ball of about 16 identical cells and is the result of the zygote dividing rapidly.

a nurse is educating a 22-year-old primigravid client about the danger signs of pregnancy. Which is a danger sign of pregnancy? a. morning sickness b. vaginal bleeding c. shortness of breath d. vaginal discharge

B Rationale: vaginal bleeding at any time during pregnancy is a danger sign and should be immediately reported to the practitioner. morning sickness, SOB, and vaginal discharge are common discomforts of pregnancy due to anatomic and physiologic changes taking place

a pt in labor is admitted to a healthcare facility with a diagnosis of a prolapsed cord. What measures should the nurse take? select all that apply. a. push the cord back into the vagina b. notify the healthcare provider at once c. monitor the fetal status d. place the client in a lateral position e. hold presenting part away from cord

B C E Rationale: the nurse must insert a sterile gloved hand into the vagina to hold the fetal presenting part away from the cord. this measure ensure that fetal circulation is not cut off while the client is being prepared for an emergency cesarean delivery. the healthcare provider must be notified at once. fetal monitoring is essential to detect any fetal distress. the cord must not be pushed back into the vagina. the client should not be placed in a lateral position but in the Trendelenburg or knee-chest position, to avoid compression of the cord.

A pregnant client in the third trimester experienced "lightening." What should the nurse instruct the client about regarding this sensation? Select all that apply. a. She may observe vaginal bleeding. b. There will be an increase in urinary frequency. c. There will be an increase in indigestion. d. She may notice increase in leg edema. e. Leg cramps may be experienced.

B D E Rationale: Lightening is the settling of the fetus into the pelvis. Lay people often say, "the baby has dropped." Lightening usually occurs 2 to 3 weeks before the onset of labor in primigravidas (women having their first child). Although lightening allows the pregnant woman to breathe more easily, the mother may feel increased pressure on the bladder causing urinary frequency. She may also have leg cramps and increased leg edema. There is less incidence of indigestion. Vaginal bleeding is not a sign of "lightening," but rather a sign of a complication and should be immediately reported to the care provider.

Which characteristic of amniotic fluid is abnormal? a. clear and colorless b. slightly salty odor c. yellow, green, or cloudy d. pH of 7.0 to 7.5

C Rationale: yellow or green fluid may indicate that the fetus has passed meconium, or stool, while still in utero and is therefore abnormal. Normal amniotic fluid is clear and colorless and has a slightly salty odor with a oH of 7.0-7.5 (neutral to slightly alkaline)

A pregnant client at 6 weeks' gestation just expelled all products of conception. What is the priority action by the nurse after this occurrence? a. Force oral fluids. b. Dispose of the products of conception. c. Observe for hemorrhage. d. Insert an indwelling catheter.

C Rationale: A complete abortion occurs when the woman spontaneously expels all the products of conception (i.e., the placenta and fetus). The uterus then contracts toward normal size, and the cervix closes. The same care that routinely follows a normal delivery is given to the woman. Observe the client closely for signs of hemorrhage. If there are any pieces of the products of conception, the uterus will have difficulty contracting back to size and the client may hemorrhage. Forcing oral fluids is not a priority at this time. The products of conception should be sent for analysis if possible and not disposed of. There is no indication that an indwelling catheter should be inserted, and may even be a potential source of infection.

The nurse is preparing to administer erythromycin 0.5% ophthalmic ointment to the newborn's eyes. What condition is the nurse preventing the newborn from contracting? a. Herpes simplex b. Human immunodeficiency virus (HIV) c. Ophthalmia neonatorum d. Syphilis

C Rationale: If the mother has gonorrhea or chlamydia infecting her reproductive organs, the birth process could result in the infant being exposed to those organisms. Even babies born by cesarean section may have been exposed. Each of these organisms can cause blindness, or ophthalmia neonatorum, if left untreated. Therefore, specific protection against them is required in most states. Erythromycin ointment, which is effective against both gonorrhea and chlamydia, is the drug of choice. It does not prevent herpes simplex, HIV, or syphilis.

a pregnant pt has spontaneously lost three successive pregnancies previously. which term best describes these abortions? a. inevitable abortion b. missed abortion c. recurrent spontaneous abortion d. complete abortion

C Rationale: Recurrent spontaneous abortion means that a woman has spontaneously lost three or more successive pregnancies. An abortion in which the loss of the products of conception cannot be prevented is known as an inevitable abortion. A missed abortion occurs when the fetus has died but remains in the uterus. Complete abortion occurs when the woman spontaneously expels all the products of conception.

a client notices that her newborn has a slightly elongated skull. How sould the nurse explain this to the client? a. caput succedaneum b. cehalohematoma c. modling d. ophthalmia neonatorum

C Rationale: Temporary molding or elongation of the infant's skull occurs during the birthing process when the infant is delivered vaginally, because of the overlap of the skull bones. Caput succedaneum is a swelling that results from an accumulation of fluid within the newborn's scalp. It is caused by pressure to the head during delivery and usually disappears within a few days. Cephal-hematoma is an accumulation of blood between the bones of the skull and the periosteum, the membrane that covers the skull. Ophthalmia neonatorum is a condition of the eye that occurs in a newborn exposed to gonorrhea or chlamydia organisms in the mother.

A client who is breastfeeding her baby complains of painful and swollen breasts and is febrile. Which should the nurse ask the client to do in order to prevent mastitis complication? a. nurse the baby on the unaffected breast only b. place cold packs on the breasts c. follow the antibiotic therapy regimen strictly d. move around as much as possible

C Rationale: The client with mastitis should follow the antibiotic therapy regimen directed by the healthcare provider. She should not nurse the baby on the unaffected breast only, place cold packs on the breasts, or move around too much. She should have mandatory bed rest. She should continue to nurse the newborn on both breasts, beginning with the unaffected breast to ease the let-down reflex on the other side. She should use hot packs on the breast for comfort.

The nurse is providing instruction to the client with recently confirmed pregnancy at 5 weeks' gestation. What should the nurse be sure to include in the instructions to prevent congenital anomalies in the embryo? a. Avoid exercise during the pregnancy. b. Maintain a diet of only fruits, vegetables, and grains. c. Avoid the consumption of alcohol. d. Over-the-counter medications are allowed but avoid all prescription medications.

C Rationale: The nurse should be sure to instruct the client to avoid direct or indirect exposure to tobacco smoke or the consumption of alcohol use, which can cause congenital anomalies, also known as birth defects. Exercise should be allowed and is recommended during pregnancy as long as it is not overly strenuous. It is acceptable to include proteins in the diet such as fish, chicken, beef, etc. Prior to taking any form of medication, the nurse should consult with the healthcare provider.

a nurse is informing a new mother about the various types of immunizations that the baby may need. which forms a part of the recommended regimen for vaccination against hepatitis B? a. first dose within 24 h after birth b. second dose at 3 mo c. third dose at 6 mo d. fourth dose at 1 yr

C Rationale: The nurse should inform the new mother that the third dose of vaccination against hepatitis B is given at 6 months of age. The first dose is given within 12 hours, not 24 hours, of birth. The second dose is given at age 1 to 2 months and not 3 months. The third dose is given at 6 months. There is no fourth dose.

which route is contraindicated for recording body temperature in the newborn? a. rectal route b. axillary route c. oral route d. tympanic route

C Rationale: The oral route of recording temperature is contraindicated in newborns because of the risk that the thermometer (probe) might break in the baby's mouth. Most newborn nurseries use the tympanic (ear) method to measure the newborn's temperature. The tympanic temperature probe may be set to convert to the rectal temperature equivalent. If the tympanic method is not used, axillary temperatures may be ordered. In some cases, a rectal temperature may be preferred.

A client receives epidural anesthesia during labor at 6 cm dilation for pain control. What nursing action is appropriate after initiation of the epidural? a. Have the client begin pushing. b. Allow the client to sit up in the chair. c. Position the client on the side with the head of bed slightly elevated. d. Position the client supine with the head of bed flat.

C Rationale: The woman receiving epidural anesthesia during labor should be positioned on her side, with her head slightly raised. If she lies on her back, a small firm pillow should be placed under her right hip so that the uterus tilts to the left. The client should not begin pushing at 6 cm dilation since it will cause swelling of the cervix with possible cessation of labor progress. The client should remain in the bed since there is decreased sensation of the lower extremities.

during an emergency delivery, a client had a laceration that involved the anal sphincter. what degree of laceration should the nurse document it as? a. 1st b. 2nd c. 3rd d. 4th

C Rationale: Third-degree laceration involves the anal sphincter. First-degree laceration involves the perineal skin and vaginal mucous membranes. Second-degree laceration involves muscles of the perineal body. Fourth-degree laceration extends to the anal canal.

when inspecting the skin of a 2 day old newborn, the nurse notices a white, thick, cheesy material in the hair and skin folds. which should the nurse consider this to be? a. erythema toxicum b. lanugo c. vernix caseosa d. acrocyanosis

C Rationale: Vernix caseosa is a white, thick, cheesy material that may be especially noticeable in the hair and skin creases of newborns. It is composed of epithelial cells and the secretions of glands and mainly functions to protect the skin from the drying effects of amniotic fluid in utero. Erythema toxicum is the development of a red, raised rash on the skin of most newborns, whose skin is highly sensitive. Lanugo is the development of fine, downy hair on the face, shoulders, and back of newborns. Acrocyanosis is the cyanotic appear-ance of the newborn's arms and legs caused by slowed peripheral circulation.

a pt who is known to have ischemic heart disease is 2 mon pregnant. the nurse knows which action is appropriate in the care of this pt? a. ask the pt to increase sodium intake b. tell the pt to exercise regularly c. assess the pt for dyspnea and chest pain d. tell the pt to gain weight to have a healthy baby

C Rationale: a pt with a history of cardiac problems should be assessed for dyspnea, chest pain, and pulmonary edema. during pregnancy, a woman with a cardiac condition should get plenty of rest and avoid activities that result in SOB. usually, sodium (salt) intake is restricted to prevent water retention. the pt should maintain a diet that will prevent excessive weight gain and water retention.

A pregnant client has been told by the nurse practitioner that she is in false labor. which is indicative of false labor? a. rhythmic uterine contractions that grow stronger b. increased duration of each contractions c. irregular pattern of uterine contractions d. lower-back pain that moves gradually around to the abdomen

C Rationale: characteristics of false labor include contractions felt low in the abdomen; irregular contractions, the inseity of which does not grow with time, no cervical changes, and no bloody show. rhythmic uterine contractions that grow stronger and increase in duration and lower-back pain that moves gradually around o the abdomen are characteristics of true labor.

a pregnant client has had two previous pregnancies. she had a miscarriage at 6 weeks the first time. she also has a 4-year-old daughter, who was born at 40 weeks of gestation. How should the pregnancy history best be summarized? a. G3, P0 b. G2, P1 c. G3, P1 d. G3, P2

C Rationale: gavida is the total number of pregnancies a female client has had, including the present one. The client has had 2 previous pregnancies; therefore, she is G3. Para is the number of babies born at 20 or more weeks of gestation. She had a miscarriage at 6 weeks the first time. she also has a 4-year-old daughter who was born at 40 wks, therefore she is P1.

a postpartum pt reports localized tenderness in the breast, redness, heat, fever, malaise, and nausea and vomiting. the nurse suspects which condition? a. thrombophelbitis b. cystitis c. mastits d. postpartum hematoma

C Rationale: mastitis is a breast infection most commonly caused by Staphylococcus aureus, Escherichia coli, and rarely Streptococcus. mastitis results in localized tenderness, redness, heat, fever, malaise, and sometimes nausea and vomiting. cystitis is an inflammation of the bladder caused by a mircoorganism and occurs frequently following childbirth due to urinary retention, residual urine, and trauma to the bladder and urethra during delivery. Thrombophelbitis involves a clot in the blood vessel, with resultant inflammation. postpartum hematoma is a condition involving bleeding into the subcutaneous tissue in the perineal area.

A client reports her last menstrual period was on July 1, 2015. When calculating the estimated date of confinement using Naegele's rule, what will the nurse document? a. April 1, 2016 b. June 18, 2016 c. April 8, 2016

C Rationale: n order to determine the date of confinement or the estimated date of delivery: Determine the date of the first day of the last menstrual period, add 7 days, subtract 3 months, and the resulting date is the estimated delivery date. If the last menstrual period was on July 1, 2015 the estimated delivery date is April 8, 2016.

a pt who delivered 6 wks ago is admitted to the hospital reporting sleep disturbances and extreme fatigue. the nurse who is performing admission collection of data knows that these may be signs of which disorder? a. postpartum blues b. postpartum psychosis c. postpartum depression d. new mother syndrome

C Rationale: postpartum psychosis can be suspected if a woman exhibits manic-depressive behaviors. less than 1% of the population has this exerpience. postpartum blues tends to start about 1 wk after delivery, peak about 5 days after onset, and subside 2 weeks after onset. new mother syndrome does not exist. postpartum depression is more serious than the blues and begins about 4wks after delivery. it can last for 6mo or more and requires medical treatment.

what percentage of births experience a spontaneous rupture of membranes? a. 90% b. 50% c. 25% d. 75%

C Rationale: spontaneous rupture of membranes without medical intervention occurs in only about 25% of all births. this means that in the remaining 75% of births, the birth attendant must artificially rupture the membranes.

which term is used for the fluid-filled, inner membrane sac surrounding the fetus? a. endometrium b. decidua c. amnion d. chorion

C Rationale: the fluid-filled, inner membrane sac surrounding the fetus is the amnion. the chorion is the outer membrane surrounding the fetus. the endometrium is the inner lining of the uterus. the decidua is the name used for the endometrium during pregnancy.

in pregnant women, for which condition does the maternal serum alpha fetoprotein blood test screen? a. maternal diabetes b. maternal bladder infections c. fetal neural tube defects d. sexually transmitted infections

C Rationale: the maternal serum alpha fetoprotein blood test is performed on pregnant women to screen for fetal neural tube defects. the 1h random glucose tolerance test is used to screen for diabetes in pregnant women, and a urine test is used to screen for bladder infections. different tests are used to screen for STDs.

when a nurse scrapes the soles of the foot of a newborn from the heel to the toe, there is a hyperextension and fanning out of the big toe. which reflex is the nurse testing? a. stepping reflex b. moro reflex c. babinski reflex d. rooting reflex

C Rationale: the nurse is testing the babinski reflex. babinski reflex occurs in newborn infants when the lateral edge and ball of the foot are gently stroked, resulting in hyperextending and fanning of the big toe. rooting reflex occurs when the lips or cheek is stroked; the newborn reacts by turning the head toward the direction of the stimulus. Moro reflex occurs when sudden noise or jarring movements cause the newborn to throw out the arms and draw up the legs. Stepping reflex results when the newborn steps with one foot and then the other when help upright with the feet touching a surface.

At what gestational age does the fetal stage begin? a. 2 wk b. 5 wk c. 7wk d. 9wk

D Rationale: the fetal stage lasts from the beginning of the 9th wk after fertilization through birth. The 2nd, 5th, and 7th week are all in the embryonic stage.

The nurse is gathering data from a client who suspects she is pregnant. Which data obtained by the nurse is of most concern regarding the presence of an ectopic pregnancy? a. The client has one living child. b. The client has early morning nausea. c. The client has a history of a lengthy labor with the first child. d. The client has a history of several pelvic infections.

D Rationale: Factors predisposing to ectopic pregnancy are tubal occlusion, an intrauterine contraceptive device, tumors, pelvic infections, endocrine imbalances, and abnormal tubal development. The symptoms of an ectopic pregnancy begin with spotting or bleeding 2 to 3 weeks after a missed menstrual period. Often pain accompanies the bleeding, which may be quite severe. Having one living child, a lengthy labor, or early morning nausea are not risk factors for the development of an ectopic pregnancy.

when inspecting a newborn, a nurse notices that the child's urinary meatus is on the underside of the penis (near the scrotum). which condition does this indicate? a. prepuce b. phimosis c. epispadia d. hypospadias

D Rationale: Hypospadias is the term used for a condition in male babies in which the urinary meatus is on the underside of the penis (near the scrotum). Prepuce (also called foreskin) is a layer of skin that covers the glans of the penis and is often adherent at birth. Phimosis is a condition in which the opening of the foreskin is so small that it cannot be pulled back at all. Epispadias is the location of the urinary meatus on the upper side of the penis.

after delivery, a client's placenta has failed to separate. what is the most appropriate action in this condition? a. ultrasound examination b. manual removal of the placenta c. postpartum uterine D&C d. support and monitor vital signs

D Rationale: Nursing measures in a client whose placenta has failed to separate include support and monitoring of vital signs. The birth attendant may need to remove the placenta manually and may perform a postpartum uterine D&C. Ultrasound examination should be done by the healthcare provider.

a nurse is assessing a newborn baby. which characteristic indicates an abnormality in the newborn? a. baby weighs 2,700 g b. baby's length in 50 cm c. head circumference is 35cm d. chest circumference is 32cm

D Rationale: The chest circumference of a normal newborn ranges from 25.5 to 30.5 cm. Thus, 32 cm is an abnormality. The normal newborn weighs 2,500 to 4,250 g. Normal newborn length ranges from 18 to 22 in (46 to 56 cm). The head usually has a circumference of 33 to 35.5 cm.

a pt is diagnosed with pregnancy induced HTN. which precaution should the nurse tell the client and her family to take? a. keep the pts room well lit b. avoid sedating the pt c. ask the pt to ambulate d. decrease external stimuli and stress

D Rationale: The nurse should ensure that there are no external stimuli or stress that would disturb the client. The room is kept quiet and fairly dark and sedatives are given to prevent convulsions. The client should be on bed rest and not asked to ambulate.

A client delivered a 3.80 kg infant 1 hour ago and is experiencing a large amount of rubra lochia with clots. What is the first action by the nurse? a. Call the primary healthcare provider. b. Have the client turn to the left side. c. Reinforce the maternity pads. d. Palpate the fundus and massage.

D Rationale: The priority action by the nurse is to palpate the fundus and massage. The uterus may have lost tone and this is why the client is having excess bleeding and clots. If this action does not slow the bleeding down, the primary care provider will need to be notified since there may be a retained portion of the placenta still attached to the uterus. Turning the client to the left side will have no effect and this is normally used when the fetus is still in utero to take the pressure off of the vena cava when hypotension occurs. Reinforcing the maternity pads will not stop the bleeding and is not an appropriate action at this time.

a client who is breastfeeding her baby complains of painful and swollen breasts. Which measure helps to relieve the nursing mother's breast engorgement? a. using medications (usually acetaminophen) as prescribed b. placing cold packs on her breasts three to four times a day c. avoiding manual expression or pumping of the breasts d. wearing a supportive bra and breastfeeding frequently

D Rationale: Wearing a supportive bra, frequent breastfeeding, and applying warm packs to the breast for 15 minutes before nursing or standing in the shower with warm water spraying on the breast for 15 minutes before nursing are measures that help to relieve the nursing mother's engorge-ment. Using medications, placing cold packs on her breasts, and avoiding manual expression or pumping are measures that can help to relieve breast engorgement in the non-nursing mother, not the nursing mother.

a nurse is assisting a pt who is in labor and is undergoing electronic fetal monitoring. the nurse knows which interpretation of electronic fetal monitoring is a sign of a healthy fetus? a. late decelerations b. variable decelerations c. decreased variability d. accelerations

D Rationale: accelerations are brief increases fo the fetal heart rate of 15 bpm or more. it is a sign fo a healthy fetus for the FHR to accelerate after movement or stimulation. decreased variability is little to no fluctuation in the FHR on an internal electronic monitor tracing and is a danger sign. it may indicate an abnormality in the fetal nervous system. it might also indicate that the mother has teaken or been given CNS depressants. variable decelerations usually indicate umbilical cord compression. late decelerations are related to placental insufficiency and indicate fetal distress.

a nurse has just assessed a newborn girl and recorded the following characteristics. which one if abnormal for a newborn? a. an elongated head b. head circumference of 14 inch c. length of 19 inch d. weight of 4.5 lb

D Rationale: at birth, the weight of a healthy newborn ranges from 5.5-9.5lbs with the average full-term infant weighing 7.5 lb. Thus, a weiht of 4.5 lb would be underweight. Normal newborn length ranges from 18-22 in, so a length of 19 in would be normal. the newborn head averages 13-14 in so a circumference of 14 in is also normal. An elongated head is normal for newborns delivered vaginally.

In caring for the newborn the nurse recognizes which finding is abnormal and will require immediate attention? a. HR of 110-150 bpm b. resp rate less than 60 per min c. hemoglobin 15-18g per 100ml blood d. blood glucose level less than 40 mg per 100 ml blood

D Rationale: blood glucose level less than 40-45 mg per 100 ml of blood suggests hypoglycemia in neonates. the normal respiratory rate for infants at rest is 30-60 breaths per min. HR in infants is usually in the range of 110-150. hemoglobin level in neonantes is normally in the range of 15-18 g per 100ml of blood because they have an increased blood volume.

a nurse is auscultating a 22-week pregnant client with a fetoscope. what does the detection of the fetal heartbeat by use of a fetoscope mean? a. possible sign of pregnancy b. probable sign of pregnancy c. presumptive sign of pregnancy d. positive sign of pregnancy

D Rationale: detection of the fetal heartbeat with a fetoscope is a positive sign of pregnancy, because it provides proof that there is a developing fetus. it is not a possible, probable, or presumptive sign, as such symptom could indicate a condition other than pregnancy

a pt has been confirmed to be pregnant. she gives a history of two previous full term normal pregnancies. how will the nurse classify the pt's pregnancy history? a. g2 p3 b. g3 p0 c. g2 p1 d. g3 p2

D Rationale: gravida is the total number of pregnancies the client has had, including the present one, and para is the number of babies born at 20 or more weeks of gestation.

a nurse is caring for a pregnant pt and will need to teach her about dietary changes that will need to be made. which is a recommended dietary need for the pregnant pt? a. restrict folic acid intake to 200 mcg daily b. increase caloric intake by 100 calories daily c. avoid using iodized salt as much as possible d. increase fluid intake to 10 glasses daily

D Rationale: increasing fluid intake to 10 glasses daily will assist in kidney and bowel function. caloric intake should be increased by approx. 300 calories daily. the recommended folic acid intake during pregnancy should increase to 600 mcg rather than 200 mcg daily. iodized salt should be used as it promotes proper function of thyroid gland.

following childbirth, a pts placenta fails to separate. the nurse knows that this very serious complication is called what? a. partial placenta previa b. total placenta previa c. abruptio placentae d. placenta accreta

D Rationale: placenta accreta or retained placenta may result from the failure of the placenta to be expressed after delivery. An abruptio placentae is the result of the abrupt premature separation of the normally implanted placenta from the uterine wall. Total or partial placenta previa occurs when the placenta implants in the lower segment of the uterus, rather than in the upper wall, partially or completely covering the cervix.

a pt who is in her 6th month of pregnancy is diagnosed with severe preeclampsia and is hospitalized. what is the nurse's responsibility in caring for this pt? a. check urine for albumin at least twice weekly b. provide a low-protein, high fat diet c. monitor vital signs at least every 8 hours d. reduce external stimuli as much as possible

D Rationale: reduction of external stimuli and stress helps to reduce the risk of seizures. the nurse should monitor vital signs at least every 2 hours and use the fetal monitor to assess fetal status. a low-fat, high-protein diet, not a low-protein, high-fat diet, may be necessary, or the pt may take NPO and have an IV, such as Ringer solution. The urine should be checked for albumin at least twice daily.

A pregnant client states to the nurse, "I have a darkening of the skin on my face since I got pregnant and don't know what it is." What is the best response by the nurse? a. "I am sure that you had this before pregnancy and just didn't notice it." b. "There is medication and creams that you can take to remove this." c. "This is an abnormal response to the pregnancy and we will notify the doctor." d. "This is melasma and is caused by hormonal changes during pregnancy."

D Rationale: regnancy causes some skin changes. A suntanned, bronzed masking may appear across the face of dark-haired women. This is known as melasma (or chloasma gravidarum), or the "mask of pregnancy." Medications and creams do not remove it and it usually goes away after pregnancy. It is a normal change during pregnancy, although all women do not experience it. Stating to the client that she had it prior to pregnancy and didn't notice it disputes the client's assessment and is an inappropriate response.

a client in her first trimester visits the prenatal clinic. which should the nurse say is the pattern of future visits? a. once every week for the first 28 weeks b. once every 2 weeks for the first 28 weeks c. once every 3 weeks for the first 28 weeks d. once every 4 weeks for the first 28 weeks

D Rationale: the nurse should inform the client that future visits to the prenatal clinic should be once every 4 weeks until the 28th week , after which the frequency of visits increases to once every 2 weeks until the 36th week and then weekly until birth