module 1 exam: developmental stages and transitions

An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? "The number of sweat glands and blood vessels decreases in the normal aging process." "A loss of melanin occurs in the normal aging process."

"A loss of melanin occurs in the normal aging process."

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. Which question should the nurse ask to identify risk factors associated with the use of an oral contraceptive?

"Do you smoke cigarettes?"

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? "Fluoride supplementation is not necessary until permanent teeth come in." "I can mix the food in my infant's bottle if he won't eat the food." "Egg white should not be given to my infant because of the risk for an allergy." Meats are really important for iron, and I should start feeding meats to my infant right away.

"Egg white should not be given to my infant because of the risk for an allergy."

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her primary health care provider. Which statement by the mother indicates a need for further information?

"Frequent urination and burning when I urinate are expected."

A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?

"I can leave the diaphragm in place as long as I want after intercourse."

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? "I should eat five or six small meals a day rather than three full meals." "I need to be sure to drink adequate fluids with my meals." "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning." "I need to avoid eating fried or greasy foods."

"I need to be sure to drink adequate fluids with my meals." To alleviate nausea and vomiting, the client should avoid drinking fluids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage.Test-Taking Strategy: Note the strategic words "need for further information." These words indicate a negative event query and the need to select the incorrect statement. Use knowledge of general principles related to nutrition and the measures to alleviate nausea and vomiting to direct you to the correct option.

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? "I need to wear additional antiperspirant and deodorant in warm weather." "I need to wear a hat with a wide brim when I go outdoors." "I should drink extra fluids during the summer." "I should wear cool, light clothing in warm weather."

"I need to wear additional antiperspirant and deodorant in warm weather."

A mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? Soon after the first primary tooth erupts, usually around 1 year of age At age 3 Twelve months after the first primary tooth erupts Just before beginning kindergarten

Soon after the first primary tooth erupts, usually around 1 year of age Rationale: The child should see the dentist soon after the first primary tooth erupts at around 1 year of age. Therefore the remaining options are incorrect. Parents should be aware of the dental guidelines for children and should not delay necessary dental care.Test-Taking Strategy: Focus on the subject, the age of the first dental visit, and recall the importance of dental care. Answer correctly by selecting the option that provides dental care at the earliest age.

A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence? Apply pressure with a finger over the umbilical area Squeeze the infant's nail beds Apply pressure with a finger on the infant's forehead

Apply pressure with a finger on the infant's forehead

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is most appropriate?

Applying an ice pack to the perineum

A nurse is performing an admission assessment on an older client who will be seen by a primary health care provider in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? Document the client's concern in the medical record. Ask the client about medications he is taking.

Ask the client about medications he is taking.

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure?

At the level of the nipples

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client?

Aunts, uncles, grandparents, and cousins

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? Drinking eight 8-oz (240 ml) glasses of fluid each day will reduce the risk of contracting influenza. It is best to do grocery shopping and other errands late in the day Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

A nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult?

Young adults ignore physical symptoms and postpone seeking health care

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which?

body image

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding? Check the client's temperature. Obtain a sample of the amniotic fluid for laboratory analysis. Report the findings to the nurse-midwife. Document the findings.

document the findings

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?

16 weeks

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure? A female primary health care provider examines the woman Written permission is obtained from the woman to obtain subjective health data The woman is examined without any other people in the examining room

A female primary health care provider examines the woman

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding? A nonreassuring sign A reassuring sign An indication of the need to contact the primary health care provider An indication of fetal distress

A reassuring sign

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist in developing which psychosocial stage? autonomy sense of trust sense of industry initiative

A sense of industry

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline Absence of accelerations after fetal movement

Absence of accelerations after fetal movement

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? Industry versus inferiority Trust versus mistrust Autonomy versus doubt and shame

Autonomy versus doubt and shame Rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their wills and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their own wills but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool-age child. Industry versus inferiority is the developmental task of the school-age child.Test-Taking Strategy: Focus on the subject in the question, the behavior of a 2-year-old toddler. Note the relationship between the strategic words "a will of his own" and the strategic word "autonomy" in the correct option.

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? Back of the fetus Brachial area of one extremity of the fetus Chest of the fetus Carotid artery in the neck of the fetus

Back of the fetus Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and to determine the location of the fetal back. The fetal heart rate is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Because of the position of the fetus in the maternal abdomen (fetal position), auscultation of the FHR over the chest, carotid artery, or brachial area is not possible.Test-Taking Strategy: Focus on the subject, where to place the fetoscope on the fetus. Visualize each of the options. Recalling the position of the fetus in the maternal abdomen will direct you to the correct option.

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? Simple board games and puzzles Blocks and push-pull toys Videos and cutting-and-pasting toys Finger paints and card games

Blocks and push-pull toys

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? Blowing repeatedly in short puffs Holding her breath and using the Valsalva maneuver Deep inspiration and expiration at the beginning and end, respectively, of each contraction

Blowing repeatedly in short puffs Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. The woman would not be encouraged to hold her breath or perform the Valsalva maneuver, which is a bearing-down maneuver.Test-Taking Strategy: Focus on the subject, overcoming the urge to push. Eliminate options that are comparable or alike; cleansing breaths include deep inspiration and expiration at the beginning and end of each contraction. Recalling that the Valsalva maneuver is a bearing-down maneuver will help you eliminate this option.

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother?

Body piercing is generally harmless as long as it is performed under sterile conditions

A school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime Brush and floss their teeth every morning and at bedtime Brush their teeth every morning and at bedtime Brush and floss their teeth after meals and at bedtime

Brush and floss their teeth after meals and at bedtime

A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take?

Checking the client's uterine fundus

A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL (2.2 mmol/L). Based on this result, which action should the nurse take first? Document the results in the newborn's medical record Contact the nurse-midwife or primary health care provider

Contact the nurse-midwife or primary health care provider The blood glucose level for a newborn infant should remain above 40 mg/dL (2.2 mmol/L). If glucose is not constantly available to the brain, permanent damage may occur. The nurse would most appropriately contact the nurse-midwife or primary health care provider to obtain prescriptions regarding feeding the infant with a low blood glucose. The nurse would also follow agency policy regarding feeding infants with a low blood glucose level if such a policy exists. A common practice is to feed the infant if the glucose level is 40 mg/dL (2.2 mmol/L) or less. Holding the next scheduled feeding is harmful. Although the nurse would document the laboratory result, this is not the most appropriate initial action. Another blood sample may need to be drawn if it is prescribed, but asking the laboratory to repeat the test in 2 hours is not the appropriate action.Test-Taking Strategy: Note the strategic word "first" in the question. Recalling the normal blood glucose level for a newborn and recalling the danger associated with a low blood glucose level will direct you to the correct option.

A nurse monitoring a client in labor notes this fetal heart rate pattern (refer to figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action?

Continue to monitor the client and fetal heart rate patterns

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which? Checking the amniotic fluid for intrauterine infection Determination of fetal lung maturity Checking the fetal cells for chromosomal abnormalities Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid

Determination of fetal lung maturity The most common indications for amniocentesis in the third trimester are determination of fetal lung maturity and evaluation of the fetus' condition when the woman has Rh isoimmunization. The most common purpose for midtrimester amniocentesis is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Midtrimester amniocentesis is also performed to evaluate the fetus' condition when the woman is sensitized to Rh-positive blood, to diagnose intrauterine infection, and to investigate amniotic-fluid AFP and acetylcholinesterase when the maternal serum AFP concentration is increased.Test-Taking Strategy: Note the strategic word "most" and the strategic words "third trimester" in the question. This will help direct you to the option that addresses fetal lung maturity. Use of the ABCs — airway, breathing, and circulation — will also direct you to the correct option.

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client? Devices that apply pressure alone are available over the counter Complementary alternative therapies should not be used during pregnancy The primary health care provider or nurse-midwife needs to provide a prescription for acupressure It is all right to try any type of complementary alternative therapy to relieve the nausea

Devices that apply pressure alone are available over the counter Rationale: As a complementary alternative therapy, acupressure over the Neiguan acupuncture point (approximately three fingers' width above the wrist crease on the inner arm) is performed with the use of electrical impulses or with a device that applies pressure alone. Devices that apply an electrical impulse over this point require a prescription from a primary health care provider or nurse-midwife. Devices that apply pressure alone are available over the counter. Certain types (those that are noninvasive and are not harmful) may be acceptable for use during pregnancy. Not all types of complementary alternative therapies can be used during pregnancy, because some may be harmful to the mother, fetus, or both.

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? Wait 15 minutes and then recheck the FHR Notify the primary health care provider of the finding Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time Document the findings

Document the findings

A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take?

Document the findings

A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? Document the findings Notify the primary health care provider immediately Obtain a prescription for a muscle relaxant Ask the primary health care provider about referring the client to a neurological specialist

Document the findings Rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying yes), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the primary health care provider immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect.Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate contact with the primary health care provider.

A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours Report the findings to the primary health care provider Ask the primary health care provider for a prescription for a nighttime sedative Document the findings in the medical record

Document the findings in the medical record Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the primary health care provider. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns.Test-Taking Strategy: Focus on the subject in the question, an older client's sleeping patterns. Recalling the age-related changes related to sleep patterns and remembering that those described in the question are normal will direct you to the correct option.

A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? Suggest to the pediatrician that a skull x-ray be performed Tell the mother that the infant is growing faster than expected Document these measurements in the infant's health-care record Suspect the presence of hydrocephalus

Document these measurements in the infant's health-care record The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect.Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate that the infant has a physiological problem.

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? "Yes, your infant is protected from all infections." "The transfer of your antibodies protects your infant until the infant is 12 months old." "If you breastfeed, your infant is protected from infection." "The immune system of an infant is immature, and the infant is at risk for infection."

The immune system of an infant is immature, and the infant is at risk for infection."

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? Discouraging social interaction, particularly at bedtime Encouraging at least one daytime nap Encouraging bedtime reading or listening to music Discouraging the use of a night light at bedtime

Encouraging bedtime reading or listening to music Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a night light will foster an environment that is both helpful and safe.Test-Taking Strategy: Thinking about the safety needs of the older client will assist you in eliminating the option of discouraging the use of a nightlight. To select from the remaining options, focusing on the subject, maintaining an adequate sleep pattern, will direct you to the correct option.

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth.

A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action?

Gently stimulate the infant by rubbing his back while administering oxygen

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? Schedule an appointment with a dentist for a dental evaluation Obtain an over-the-counter (OTC) topical medication for gum-pain relief Rub the infant's gums with baby aspirin that has been dissolved in water Give the infant cool liquids or a Popsicle and hard foods such as dry toast

Give the infant cool liquids or a Popsicle and hard foods such as dry toast

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. Based on this finding, what does the nurse determine? The client needs to receive the hepatitis B series of vaccines The results are negative Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth The results indicate that the mother does not have hepatitis B

Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth Rationale: A hepatitis B screen is performed to determine the presence of antigens in maternal blood. If they are present, the newborn will need to receive hepatitis immune globulin and vaccine soon after birth. Therefore, noting that the results are negative, noting that the client needs to receive the hepatitis B series of vaccines, and noting that the results indicate that the mother does not have hepatitis B are all incorrect interpretations.Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate that the results are negative and that the mother does not have hepatitis B. To select from the remaining options, recall the significance of antigens in maternal blood, which will direct you to the correct option.Review: the significance of the hepatitis B screen during pregnancy.

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes that the menstrual pad was saturated in 15 minutes. What should be the nurse's next action?

Immediately contact the primary health care provider.

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? Allow the toddler to play with other children in the nursing unit playroom Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room Keep hospital routines as similar as possible to those at home Spend as much time as possible with the toddler

Keep hospital routines as similar as possible to those at home

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age-related finding? Thick skin on the lower legs Bounding dorsalis pedis pulse Thin, ridged toenails Loss of hair on the lower legs

Loss of hair on the lower legs

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? Ensuring that most of the diet consists of liquids Encouraging the client to feed herself Consulting with the health care provider regarding feeding through an enteral tube Monitoring the client during meals to ensure that food is swallowed

Monitoring the client during meals to ensure that food is swallowed

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? Experience frustration to allow an infant to cry for a while before meeting his or her needs Rely on the fact that their needs will be met Tolerate a great deal of frustration and discomfort to develop a healthy personality Ignore needs for short periods to develop a healthy personality

Rely on the fact that their needs will be met Rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect.Test-Taking Strategy: Eliminate the option that contains the closed-ended word "must." Eliminate the options that are comparable or alike and indicate that experiencing frustration is necessary.

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. Asks the mother to lie still while both the FHR and the radial pulse rate are counted

Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic souffle (blood flowing through the umbilical cord) and the uterine souffle (blood flowing through the uterine vessels). The funic souffle is synchronized with the FHR; the uterine souffle is synchronized with the mother's pulse.Test-Taking Strategy: Focus on the subject of the question, the FHR. Noting that the sounds heard through the fetoscope are synchronized with the mother's radial pulse will help direct you to the correct option. Also note that the incorrect options are comparable or alike in that they indicate continuing with the counting of the heart rate.

Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? The primary health care provider should be notified immediately if breast engorgement occurs If the oral tablets are not successful, the medication will be administered intravenously The couple should engage in coitus once a week during treatment Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F (38.1°C), the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action? Document the findings in the client's medical record Continue collecting subjective and objective data Notify the nurse-midwife of the findings Recheck the vital signs in 1 hour

Notify the nurse-midwife of the findings

A prescription is written to administer hepatitis B vaccine to a newborn infant. Before administering the vaccine, which action should the nurse take?

Obtain parental consent to administer the vaccine

A nurse is discussing birth control methods with a client who is trying to decide which method to use. The nurse should focus on which major factor that will provide the motivation needed for consistent implementation of a birth control method? Family planning goals Personal preference Work and home schedules Desire to have children in the future

Personal preference

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately notfy the nurse-midwife or primary health care providor Perform a vaginal examination on the mother Insert a gloved finger into the mother's vagina to feel for cord compression Position the mother so that her hips are elevated

Position the mother so that her hips are elevated Rationale: Conditions that restrict blood flow through the umbilical cord may result in variable decelerations. If cord compression is suspected, the mother is immediately repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal presenting part toward her diaphragm. A hands-and-knees position may also reduce compression of a cord that is trapped behind the fetus. Several position changes may be required before the pattern improves or resolves. The nurse may need to contact the nurse-midwife or primary health care provider, but this would not be the immediate action. Although the nurse may check the woman's vaginal area for the presence of the umbilical cord, a vaginal exam is not performed because of the possibility of further compromise of blood flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved finger into the vagina to feel for the cord.Test-Taking Strategy: Note the strategic word "immediately" in the question and use the ABCs — airway, breathing, and circulation — to answer the question. The only action that would provide circulation is positioning the mother so that her hips are elevated, which would relieve cord compression.Review: The immediate nursing measures when cord compression is suspected

A nurse is telling a pregnant client about the signs/symptoms that must be reported to the primary health care provider or nurse-midwife. The nurse tells the client that the primary health care provider or nurse-midwife should be contacted if which occurs? Puffiness of the face Urinary frequency Breast tenderness Morning sickness

Puffiness of the face

The mother of a 9-year-old child who is 5 feet 1 inch (155 cm) in height asks a nurse about car safety seats. What should the nurse tell the mother to use? Rear convertible seat Forward-facing car seat Rear seat using lap and shoulder seat belts Front booster seat

Rear seat using lap and shoulder seat belts Rationale: All infants and toddlers should ride in a Rear-Facing Car Seat until they are at least 2 years of age or until they reach the highest weight or height allowed by their car seat's manufacturer. ​Any child who has outgrown the rear-facing weight or height limit for their convertible car seat should use a Forward-Facing Car Seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. All children whose weight or height is above the forward-facing limit for their car seat should use a Belt-Positioning Booster Seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches (145 cm) in height and are between 8 and 12 years of age.​ When children are old enough and large enough for the vehicle seat belt to fit them correctly, they should always use Lap and Shoulder Seat Belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.Test-Taking Strategy: Note the subject, a 9-year-old child who is 4 feet 11 inches (150 cm) in height. Keeping the subject of safety in mind and visualizing each of the options will direct you to the correct option.

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take? Tell the mother that the infant's weight is increasing as expected Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes Tell the mother to decrease the daily number of feedings because the weight gain is excessive Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate

Tell the mother that the infant's weight is increasing as expected Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz (2.9 kg), at birth, a weight of 13 lb (5.9 kg) at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age.Test-Taking Strategy: Focus on the subject in the question, the current weight of the infant. Recalling that infants double their weight by 6 months of age will direct you to the correct option.

A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. What should the nurse tell the mother? To separate her children during playtime That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity That if the behavior continues, she will need to bring her children to a child psychologist To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity

A female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client?

That it offers protection against sexually transmitted infections (STIs

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client? She will be positioned on her back for the procedure The procedure takes about 2 hours A probe coated with gel will be inserted into the vagina That she may need to drink fluids before the test and may not void until the test has been completed

That she may need to drink fluids before the test and may not void until the test has been completed For a transabdominal ultrasound, the woman is positioned on her back, with her head elevated, but is turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure takes 10 to 30 minutes. For transvaginal ultrasonography, a transvaginal probe is inserted into the vagina.Test-Taking Strategy: Note the strategic word "transabdominal" in the question and eliminate the option that contains the words "inserted into the vagina." Recalling that the pregnant client is at risk for supine hypotension will help you eliminate the option that involves positioning the client on her back. To select from the remaining options, visualize this procedure and eliminate the option stating that the test will take 2 hours, because this is a lengthy period.

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother? To bring the infant to the pediatrician's office to be checked That the crust is to be expected as a normal part of healing That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours To remove the crust, using a warm, wet face cloth and a mild soap

That the crust is to be expected as a normal part of healing

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents?

That this is normal behavior for an adolescent

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? The child no longer has temper tantrums. The child can eat using a fork and knife. The child can remove his or her own clothing. The child has been walking for 2 years.

The child can remove his or her own clothing.

A nurse reviews the health history of a client who will be seeing the primary health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? The client has hyperlipidemia. The client is being treated for hypertension. The client has type 2 diabetes mellitus. The client has been treated for breast cancer.

The client has been treated for breast cancer.

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? "The drop side needs to be impossible for my infant to release." I need to keep large toys out of the crib." "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body." "Wood surfaces on the crib need to be free of splinters and cracks."

The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body." Rationale: The distance between slats must be no more than 2 ⅜ inches (6 cm) to prevent entrapment of the infant's head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch (.5 cm). The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib, because an older infant may use them as steps to climb over the side, possibly resulting in serious injury.Test-Taking Strategy: Note the strategic words "need for further instructions" in the question. These words indicate a negative event query and the need to select the incorrect statement by the mother. Visualizing each of these options and keeping safety in mind will direct you to the correct option.

A nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? The normal aging process increases the production of surfactant The normal aging process increases respiratory system compliance The normal aging process decreases the number of alveoli and increases the function of those remaining The normal aging process decreases an older client's ability to clear secretions

The normal aging process decreases an older client's ability to clear secretions Rationale: Respiratory changes related to the normal aging process decrease an older adult's ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished.Test-Taking Strategy: Focus on the subject, the normal age-related changes in the older client. Note the relationship between the strategic words "maintain a patent airway" in the question and "ability to clear secretions" in the correct option.

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. What should the nurse tell the client? She has developed immunity to the rubella virus The test results are normal The test will need to be repeated during the pregnancy She must have been exposed to the rubella virus at some point in her life

The test will need to be repeated during the pregnancy Rationale: A client is not immune to rubella if the titer is 1:8 or less. If the client is not immune, retesting will be performed during the pregnancy. Additionally, rubella immunization is required after delivery if the client is not immune. Therefore telling the client that she has developed immunity to the rubella virus, telling her that she may have been exposed to rubella, and telling her that the test results are normal are all incorrect.Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate that the results are normal or that the woman has developed immunity.

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted? There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. The toes flare and the big toe is dorsiflexed. The infant turns to the side that is touched. The fingers curl tightly and the toes curl forward

The toes flare and the big toe is dorsiflexed.

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother?

This is normal for breastfed infants.

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz (3.2 kg) about car safety. What should the nurse tell the mother? To secure the infant in the middle of the back seat in a rear-facing infant safety seat That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant

To secure the infant in the middle of the back seat in a rear-facing infant safety seat

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action?

Uncovers only the body part being washed

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? Use of a latex condom can prevent transmission of STIs Use of a latex condom is a good method for preventing pregnancy A spermicide needs to be used along with a condom to prevent transmission of STIs

Use of a latex condom can prevent transmission of STIs Rationale: Use of a condom during intercourse can prevent transmission of STIs. Abstinence is not the only way to prevent transmission of an STI. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs.Test-Taking Strategy: Focus on the subject, preventing transmission of an STI. Eliminate the option using the closed-ended word "only." Focusing on the subject will help you select the correct option from the remaining options.

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? Use water and a cotton swab and rub the teeth Use a small amount of toothpaste and a soft-bristle toothbrush Use diluted fluoride and rub the teeth with a soft washcloth

Use water and a cotton swab and rub the teeth Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay.Test-Taking Strategy: Focus on the subject, cleaning the teeth. Recalling the risk associated with tooth decay will help eliminate the option that identifies the use of maple syrup. To select from the remaining options, noting that the client in the question is an infant will direct you to the correct option.

Intramuscular phytonadione 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it?

Vastus lateralis muscle

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate? Documenting the finding Reporting the finding to the nurse-midwife or primary health care provider immediately Performing active and passive range-of-motion exercises Helping the woman get out of bed and walk

document thr finding Test-Taking Strategy: Note the strategic words "most appropriate." Recalling the physiological alterations that occur in the woman after delivery will direct you to the correct option. Remember that after delivery bradycardia may occur and that it is a normal finding.

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? Stethoscope Fetoscope Pulse oximetry on the client and a fetoscope Doppler transducer

doppler transducer

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations?

every 6 months

A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? Supine Standing Hands and knees prone

hands and knees "Back labor," in which the back of the fetal head puts pressure on the woman's sacral promontory (occiput posterior position), is common. The discomfort of back labor is difficult to relieve with medication alone. Positions that encourage the fetus to move away from the sacral promontory are the hands-and-knees position and leaning forward over a birthing ball (a sturdy ball similar to a beach ball). These positions reduce back pain and enhance the internal-rotation mechanism of labor. It would be difficult for the woman to assume a prone position. The supine position places the client at risk for supine hypotension. A standing position might increase pressure, worsening the woman's backache.Test-Taking Strategy: Focus on the subject of the question, relieving back discomfort, and note the strategic word "best" in the question. Visualizing each of the positions in the options will direct you to the correct option.

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman?

headache

A nurse observes an assistive personnel (AP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the AP performs which action? Uses facial expressions or gestures Speaks at a normal rate and volume uses short sentences over articulates words

over articulates words Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the AP avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the AP to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The AP should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues.Test-Taking Strategy: Focus on the subject, communicating with a hearing-impaired client Note the strategic word "intervene" in the query of the question. This word indicates a negative event query, in which you need to select the option that indicates an incorrect action by the AP. Visualize each of the options to help direct you to the correct one.

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? Oranges Lettuce Broccoli Pinto beans

pinto beans

A nurse is performing an external and ophthalmoscopic examination of an older client. Which age-related change would the nurse expect to note?

smal pupil Rationale: Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula. Conjunctivitis is not an age-related change and is characterized by the presence of a red sclera. Purulent material in the anterior chamber of the eye occurs with iritis and is not an age-related change. It is characterized by the presence of white material or drainage in the eye. Red blood vessels, a clear fundus, and a yellow-orange optic disc are all normal, not age-related, findings.Test-Taking Strategy: Focus on the subject, an age-related finding. Eliminate the options that are comparable or alike and identify infections. To select from the remaining options, recalling the normal color of the optic disc will direct you to the correct option.

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? Male condom Diaphragm Sterilization spermicide

sterilization Rationale: If family planning goals have already been met, sterilization of the male or female partner may be desirable. When sexual activity is limited, use of a spermicide, condom, or diaphragm may be most appropriate.Test-Taking Strategy: Focus on the data in the question and note that the couple is sexually active and is seeking a method of birth control that is convenient. Eliminate the options that are comparable or alike and involve the application of a contraceptive method.

Test-Taking Strategy: Note the strategic words "most appropriate." Recalling the physiological alterations that occur in the woman after delivery will direct you to the correct option. Remember that after delivery bradycardia may occur and that it is a normal finding.

stopping the oxytocin infusion