NUR404 exam 4

When assessing newborns for chromosomal disorders, which assessment would be most suggestive of a problem? A. low-set ears B. slanting of the palpebral fissure C. short neck D. bowed legs

A A number of common chromosomal disorders, such as trisomies, include low-set ears.

The parents of a 6-year-old have just been told that their child will die shortly. At which age does the nurse realize that children are capable of understanding death? A. 3 years B. 6 years C. 9 years D. 12 years

C As children near 8 or 9 years of age, they begin to appreciate that death is permanent. Younger children are not able to conceptualize the permanence of death. A 12-year-old child is able to conceptualize the permanence of death.

A couple is undergoing fertility testing. The male partner is scheduled for semen analysis. When teaching the male partner about this procedure, the nurse would instruct him to refrain from sexual intercourse for which time frame before the analysis? A. 4 to 8 hours B. 12 to 24 hours C. 2 to 4 days D. at least 1 week

C For a semen analysis, a client should be instructed to be sexually abstinent for 2 to 4 days before the analysis.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: A. assess the rate of flow of the oxytocin infusion. B. administer oral orange juice for added potassium. C. assess her vaginally for full dilation (dilatation). D. instruct her to breathe in and out rapidly.

A A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

An adolescent is prescribed tretinoin (Retin-A cream) as therapy for acne. After teachigthe adolescent about this medication, the nurse determines that the teaching was successful based on which client statement? A. "I need to make sure I protect myself when I'm outside." B. "I should apply the cream while my face is wet." C. "I should avoid using the medication prior to bedtime." D. "The cream should not be applied directly to the acne lesions."

A A common prescription medication for acne is tretinoin (Retin-A cream). This medication reduces keratin formation and plugging of ducts. Adolescents should be cautioned to avoid prolonged sun exposure and to use a sunblock of SPF 15 or higher because the preparation makes their skin more susceptible than usual to ultraviolet rays. This medication is not typically applied to a wet face. It can be used prior to bedtime. It should be applied directly to lesions.

An adolescent asks the nurse what the term "puberty" means. What is the nurse'sbest response? A. "It is the age at which one first becomes capable of sexual reproduction." B. "It denotes the beginning of secondary sex characteristics." C. "It is the time span between 12 and 18 years." D. "It is the time span that denotes the onset of maturity."

A Adolescence is a period of rapid growth with dramatic changes in body size and proportions. It is the time between puberty and the end of physical growth. During this time, sexual characteristics develop and reproductive maturity occurs. Puberty is the point at which an individual becomes capable of sexual reproduction. Puberty starts at different ages for males and females. Puberty is defined as sexual maturity only. It does not describe emotional maturity

A client recovering from a surgical pregnancy termination returns for a postprocedure examination. The client tells the nurse that she is relieved that the procedure is over but that she is feeling sad. What should the nurse do to assist the client at this time? A. Suggest the client talk with a counselor. B. Ask the client to identify the source of the sadness. C. Recommend the client attend contraceptive counseling sessions. D. Discuss the need for an antidepressant with the health care provider.

A After a surgical pregnancy termination, most women report to be relieved with the decision; however, those who express sadness and guilt may need to be referred for professional counseling so they can integrate and accept this event in their lives. Asking the client to identify the source of the sadness will not help her work through feelings caused by the procedure. Recommending the client attend contraceptive counseling sessions does not focus on the source of her sadness. Discussing antidepressant use may be premature for this client.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: A. administer oxygen by mask. B. increase her intravenous fluid infusion rate. C. put firm pressure on the fundus of her uterus. D. tell the woman to take short, catchy breaths.

A An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A woman who has a recessive gene for sickle cell anemia marries a man who also has a recessive gene for sickle cell anemia. Their first child is born with sickle cell anemia. The chance that their second child will develop this disease is: A. 1 in 4. B. 2 in 4. C. 3 in 4. D. 0 in 4.

A Autosomal recessive inherited diseases occur at a 1-in-4 incidence in offspring. The possibility of a chance happening does not change for a second pregnancy.

An infant was born after a face presentation. When selecting a nursing diagnosis for the newborn, which body system does the nurse identify as a priority? A. respiratory B. genitourinary C. cardiovascular D. gastrointestinal

A Babies born after a face presentation have a great deal of facial edema and maybe purple from bruising. The infant must be observed closely for a patent airway, which is the priority. A face presentation does not affect the cardiovascular or genitourinary systems. If lipedema is severe, the newborn might need gavage feedings until the edema subsides and sucking can occur.

The nurse is asked to schedule a hysterosalpingogram. Which question would be most important for the nurse to ask the woman before scheduling the procedure? A. When do you expect your next menstrual flow? B. Are you allergic to any sedatives? C. What is your blood type and Rh factor? D. When did you have sex last?

A Because a radiograph is involved, the procedure should be done in the few days following a menstrual flow when she is not apt to be pregnant.

The nurse is caring for a client in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this client's discomfort? A. Massage the lower back. B. Place in a prone position. C. Apply ice packs to the lower back. D. Place in the Trendelenburg position.

A Because the fetal head rotates against the sacrum in the occiput posterior position, the client may experience pressure and pain in the lower back because of sacral nerve compression. Applying counter pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain. The client does not need to be placed in the prone or Trendelenburg positions. Ice packs are not indicated to reduce this pain.

A pregnant client receiving intravenous oxytocin for 1 hour has contractions lasting 85 seconds. What should the nurse do first for this client? A. Discontinue the oxytocin infusion. B. Slow the infusion to below 10 gtt/minute. C. Increase the flow rate of the main line infusion. D. Continue to monitor contraction duration every 2 hours.

A Contractions should last no longer than 70 seconds. If contractions become longer in duration, stop the IV infusion and seek help immediately. The infusion needs to be discontinued and not slowed. Increasing the flow rate could cause fetal distress. The client needs to be assessed more frequently than every 2 hours.

The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? A. Decorticate posturing and fixed and dilated pupils B. Decreased pupil reaction and decreased respiration. C. Headache and sunset eyes D. Dizziness and irritability

A Decerebrate or decorticate posturing and fixed and dilated pupils are late signs of increased intracranial pressure. Decreased pupil reaction, decreased respirations, headache, sunset eyes, dizziness, and irritability are early signs of increased intracranial pressure.

A 14-year-old adolescent is suspected of having scoliosis. When doing scoliosis screening, what observation would be important for the nurse to note? A. The posterior spine when bending forward B. The angle of the iliac crest when bending forward C. The posterior spine when bending sideways D. The angle of the lower chest when sitting down

A Diagnosis of scoliosis is best made with inspection and observation. When inspecting the back with the child in a standing position, the nurse should note asymmetries such as shoulder elevation, the prominence of one scapula, an uneven curve at the waistline, or a rib hump on one side. A lateral curvature of the spine is best revealed when the child bends forward. The child should bend forward with the arms hanging freely. The curve and asymmetry of the back can be observed. The height of the iliac crest, not the angle, is measured on both sides and the difference is noted. Bending to the side would not provide an accurate assessment of the spine because the curvature cannot be seen from the side. The lower chest angle would not be an accurate assessment as it would be more associated with the ribs as opposed to the spine.

A male is diagnosed as being infertile, but he wants to have children with his spouse. Which response should the nurse provide to this client? A. "You need to consider donor-alternative insemination." B. "The chance of conception is slight with artificial insemination." C. "You and your sexual partner should consider embryo transfer first because it is safer." D. "Artificial insemination is useful only if your sexual partner has an allergy to your sperm."

A Donor sperm (alternative insemination by donor) is used if the man has no sperm. There is no evidence to support that the chance of conception is slight with artificial insemination. Embryo transfer is for the female partner who does not produce ova. Artificial insemination is useful for many different situations.

The nurse is preparing an educational session for adolescents to best ensure a lifelong healthy musculoskeletal system. Which teaching will be beneficial to the most attendees? A. importance of daily exercise B. need for early diagnosis of painful joints C. need for at least 8 hours of sleep each night D. adequate intake of calcium in dietary or supplement form

A Everyone benefits by understanding the need for physical activity throughout the lifespan. The nurse can help the adolescents achieve musculoskeletal health by educating them at this time on the importance of physical activity. Physical activity strengthens the bones and muscles and develops healthy habits. The other options are important but not as important. Diagnosis of painful joints allows for early diagnosis and treatment for those who may have future problems. Sleeping at least 8 hours per night provides for repair of body tissues, restores focus, and reenergizes the body. Dietary calcium intake, which is important in bone and muscle health, is not the most important information to teach to ensure a healthy musculoskeletal system.

A husband is worried he has an inadequate sperm count. Which circumstance would be most important for the nurse to ask about during his health history? A. if he works at a desk job B. if he maintains a low-lipid diet C. if he jogs frequently D. if he takes a vitamin supplement

A Excessive heat to testicles, such as that created by sitting for long periods, may interfere with sperm production or survival.

A 16-year-old girl presents to the emergency department following a rape. Which action will the nurse complete first? A. Provide the client privacy and assess for injuries. B. Counsel the client to help increase self-esteem. C. Arrange for a follow-up visit for treatment. D. Assist the client with showering and hygiene.

A Following sexual assault (rape), the nurse's first action should focus on physical safety for the client, which includes providing privacy to help the client feel safe and assessing for physical injuries that may require medical treatment. After stabilizing the client, the nurse will allow the sexual assault nurse examiner (SANE) to collect evidence, if desired by the client, before assisting the client with showering/hygiene. Next, the nurse can arrange for counseling and a follow-up visit as needed to ensure appropriate psychological and physical care is provided.

The nurse is evaluating care provided to a client giving birth to her first child.Which outcome regarding labor indicates that care has been effective? A. A client achieved 4 cm of dilation after 7 hours of labor. B. A client achieved full dilatation after 8 hours of labor. C. A client delivered the infant within 2 hours after full dilatation with epidural. D. A client delivered the infant within 30 minutes after full dilatation without an epidural.

A For a nulliparous client, achievement of 4 cm of dilation after 7 hours of labor is expected and indicates that care has been effective. Full dilatation after 8 hours is appropriate for a multiparous client. Delivering the infant within 2 hours after full dilatation with an epidural is appropriate for a multiparous client. Delivering the infant within 30 minutes after full dilatation without an epidural is appropriate for a multiparous client without an epidural.

A woman is going to have in vitro fertilization. When preparing her for this,the nurse would make which statement? A. "It can be done with frozen donor sperm." B. "You will need to select a surrogate mother." C. "Most procedures are effective the first time tried." D. "This is dangerous if there is ovarian cancer in your family."

A Fresh or frozen sperm may be used. The success of in vitro fertilization is not related to the incidence of ovarian cancer in the family. Quite often, more than one attempt is needed before successful implantation.

The community nurse is visiting a victim of rape at home. Which observation indicates that crisis intervention goals have not been met? A. Husband hopes to meet the rapist in a back alley one day. B. Victim and husband sit with the nurse at the kitchen table and discuss feelings. C. Victim states that an intimate relationship with the husband has resumed without incident. D. Husband holds the victim's hand and expresses endearing terms while the victim smiles.

A Goals of crisis intervention for families of rape victims include helpingthe family be supportive of the victim, discussing the sexual relationship between partners, and the partner expressing that feelings have not changed. A goal is also to discourage violent retribution toward the rapist. The husband desiring to meet the rapist in a back alley indicates that crisis intervention goals have not been met.

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to: A. place a hand gently on the fetal head to guide birth. B. ask her to push with the next contraction so birth is rapid. C. assess blood pressure and pulse to detect placental bleeding. D. attach a fetal monitor to determine fetal status.

A If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix is less apt to occur.

The nurse instructs a client on the use of a vaginal estrogen/progestin (contraceptive) ring. Which client statement indicates that additional instruction is needed? A. "I am to take the ring out overnight." B. "I will leave the ring in place for 3 weeks." C. "I leave the ring in place during intercourse." D. "I am to use other birth control if I take the ring out for 4 hours."

A If the ring is removed for 4 hours for any purpose, it should be replaced with a new ring and a form of barrier protection is to be used for the next 7 days. The ring is not removed overnight. The ring is left in place for 3 weeks and then removed for menstruation during the ring-free week. The ring does not need to be removed for intercourse.

A nurse is conducting a class for a group of young adults about the menstrual cycle and the hormones involved. Which hormone will the nurse explain as initiating the proliferation of the endometrium? A. estrogen B. progesterone C. prostaglandin D. luteinizing hormone

A Immediately after a menstrual flow (which occurs during the first 4 or 5 days of a cycle), the endometrium (lining of the uterus) is very thin, approximately one cell layer in depth. As the ovary begins to produce estrogen (in the follicular fluid, under the direction of the pituitary follicle-stimulating hormone), the endometrium begins to proliferate so rapidly that the thickness of the endometrium increases as much as eightfold from day 5 to day 14. After ovulation, the formation of progesterone in the corpus luteum (under the direction of luteinizing hormone) causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen (an elementary sugar) and mucin (a protein). Release of prostaglandins on about day 14 leads to ovulation.

The mother of a terminally ill child stays with the child day and night. Which statement indicates that the mother is in the chronic sorrow of depression stage? A. "I will never accept that my child is dying." B. "I know that there is nothing that can be done for my child." C. "There must be another doctor somewhere that can help my child." D. "I will go to church every week if this will keep my child from dying."

A In the stage of depression, parents begin to face what is happening. They feel sad and unprotected. Some parents never reach the stage of acceptance and will always remain in the chronic sorrow of the depression stage. Saying that the child's dying will never be accepted indicates the chronic sorrow of depression stage. Knowing that nothing can be done for the child is acceptance. Looking for another doctor to help the child is the stage of anger. Going to church every week to prevent the child from dying is bargaining.

A young adult client comes to the clinic for a routine visit. During the visit, the client asks the nurse, "When would ovulation happen during my cycle?" Assessment reveals that the client's cycle is regular and typically 32 days. Which response by the nurse is appropriate? A. "You would ovulate on day 18 of your cycle." B. "You would likely ovulate on day 16, the middle of your cycle." C. "Ovulation is always on day 14 of your cycle regardless of cycle length." D. "There is no way to tell what day ovulation would happen."

A It is important to teach clients that ovulation does not necessarily occur on the 14th day of their cycle or in the middle of their cycle. It occurs 14 days before the end of their cycle. For this client, it would be day 18.

When teaching an adolescent about ovulation, the nurse would include that ovulation is initiated by a surge in which hormone? A. luteinizing hormone B. progesterone C. follicle-stimulating hormone D. estrogen

A Luteinizing hormone is released from the pituitary gland to stimulate ovulation on approximately the 14th day of a typical cycle.

A child with acute lymphoblastic leukemia (ALL) is receiving methotrexate for therapy. Which nursing diagnosis would best apply during therapy? A. Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy B. Risk for impaired mobility related to depressant effects of methotrexate C. Excess fluid volume related to effect of methotrexate on aldosterone secretion D. Risk for self-directed violence related to effect of methotrexate on central nervous system

A Methotrexate is a chemotherapeutic agent; one of its side effects is oral mucositis. Oral ulcerations can interfere with nutrition because of pain and leave a portal for infection. Mucositis can be treated with oral swish and swallow agents or swish and spit agents (diphenhydramine, lidocaine, nystatin). Mucositis is very painful and children will not be able to eat, so alternate ways of delivering nutrition may be necessary. The child receiving methotrexate may need large volumes of hydration to prevent dehydration from the medication effects. The nursing diagnosis of fluid overload from aldosterone production would be incorrect. Methotrexate works on specific cells. It does not affect the central nervous system. The child may have decreased mobility from the cancer effects and any side effects of many drugs the child is receiving as a result of a weakened state, but methotrexate is not a depressant.

The nurse is assessing a client in labor. On which complication of laboras identified within the 2030 National Health Goals will the nurse focus? A. uterine rupture B. prolapsed fetal cord C. hypotonic contractions D. hypertonic contractions

A Nurses can help the nation achieve the 2020 National Health Goals for complications of labor by being alert to the preliminary symptoms of uterine rupture, which accounts for a substantial number of maternal deaths during labor. Hypotonic and hypertonic contractions and prolapsed fetal cord are not identified as specific complications of labor within the 2020 National Health Goals.

The nurse is caring for a 17-year-old client recovering from a failed suicide attempt. Which factor should the nurse recognize as potentially causing the client to reattempt suicide? A. The client states feeling sad. B. The client has three other siblings. C. The client performs in the school band. D. The client is on the honor roll at school.

A Some degree of depression is present in most adolescents because they are not only losing their parents at this time as they grow apart from them but they are also losing their carefree childhood. Feeling sad is an indication of depression. Having siblings, performing in the school band, and being on the honor roll are not identified as factors for the client to reattempt suicide.

After reviewing the various types of contraception available and discussing the pros and cons about each with the nurse, a young woman decides to use a spermicidal cream. When teaching the woman about this type of contraception, the nurse would instruct the woman to insert the cream at which time frame before intercourse? A. 1 hour B. 1.5 hours C. 2 hours D. 3 hours

A Spermicidal gels or creams are easily inserted into the vagina before sex with the provided applicator. The woman should do this no more than 1 hour before sex.

An adolescent describes her menstrual pattern to the nurse. Which observation is typical of a usual menstrual pattern? A. Flow usually lasts 4 to 6 days. B. The usual cycle is 36 days. C. The average amount of flow is 500 ml. D. Menstruation typically begins at 18 years

A The average menstrual flow is 4 to 6 days in length; the cycle is 28 days; the average flow is 25 to 60 ml. Average age of onset is 12 to 14 years.

A nurse is assessing the menstrual pattern of a 17-year-old-client whose menarche occurred at age 12. The assessment reveals the following: Flow amount: saturation of 1 tampon, 45 minutes Duration: 4 to 5 days Cycle length: 30 to 32 days Flow color: dark red Which finding is a cause for concern? A. flow amount B. duration C. cycle length D. color

A The average menstrual flow is about 30 to 80 ml per menstrual period. Saturating a pad or tampon in less than 1 hour is considered heavy bleeding and is a cause for concern. The length of menstrual cycles differs from person to person, but the average length is 28 days (from the beginning of one menstrual flow to the beginning of the next). It is not unusual for cycles to be as short as 23 days or as long as 35 days. The length of the average menstrual flow (termed menses) is 4 to 6 days, although an individual may have a menstrual flow as short as 2 days or as long as 9 days. The typical color is dark red.

A child is diagnosed with Turner syndrome. The nurse understands that this condition is associated with which genetic problem? A. only 1 functional X chromosome B. missing portion of chromosome 5 C. three copies of chromosome 18 D. extra chromosome 13

A The child with Turner syndrome (gonadal dysgenesis) has only one functioning X chromosome. Cri-du-chat syndrome is the result of a missing portion of chromosome 5. Children with trisomy 18 syndrome (Edwards syndrome) have three copies of chromosome 18. In trisomy 13 syndrome (Patau syndrome), the child has an extra chromosome 1.

A multipara client in labor is having contractions which are 2 minutes apart but rarely over 50 mm Hg in strength; the resting uterine tone is high, 20 to 25 mm Hg. The client asks what she can do to make contractions more effective. The nurse's best response is: A. rest between contractions. B. request oxytocin to strengthen the contractions. C. be patient as contractions will strengthen by themselves. D. ambulate to make the contractions regular.

A The client's contractions are hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest, not activity, is effective in helping contractions become more productive. Oxytocin is contraindicated. There is no guarantee that waiting will change the status of the contractions.

While the placenta is being delivered after labor, a client experiences an amniotic fluid embolism. What should the nurse do first to help this client? A. Administer oxygen by nasal cannula. B. Increase intravenous fluid infusion rate. C. Put firm pressure on the fundus of the uterus. D. Tell the client to take short, shallow breaths.

A The clinical picture of an amniotic fluid embolism is dramatic. The client suddenly experiences sharp chest pain and is unable to breathe as pulmonary artery constriction occurs. The immediate management is oxygen administration by face mask or cannula. Intravenous fluids; pressure on the fundus; or taking short, shallow breaths is not going to help the manifestations of an amniotic fluid embolism.

A nurse is asked to teach a woman to take her basal body temperature dailyto assess the time of ovulation. She can detect her day of ovulation, following ovulation, because her temperature will: A. increase a degree. B. decrease a degree. C. fluctuate a degree daily. D. no longer reflect basal body temperature.

A The effect of progesterone, released with ovulation, is to increase body temperature.

At the completion of a health interview, the nurse is concerned that a newborn is atrisk for maltreatment. Which observation caused the nurse to come to this conclusion? A. Mother does not look at the baby. B. Mother helps the nurse loosen the baby's clothing for a physical examination. C. Mother explains that the husband helps with feeding the baby during the night. D. Mother quickly changes a dirty diaper and uses personal supplies to cleanse the child.

A The mother's inability to establish eye contact, or maintain a direct en face position with the baby, can indicate the potential for child abuse (child maltreatment). Helping the nurse loosen clothing for an examination, identifying someone to help with child care, and prompt attention to the baby's needs when changing a soiled diaper indicate the mother is bonding with the child, and the child is not at risk for maltreatment.

The nurse is caring for a 16-year-old client. The client confides in the nurse that they use of marijuana daily. Which action by the nurse is appropriate? A. Discuss adverse side effects with the client. B. Notify local law enforcement. C. Ask the client where the marijuana is obtained. D. Determine how long the client has used marijuana.

A The nurse will first discuss adverse side effects of marijuana use withthe client. The nurse is not legally bound to notify law enforcement and this would be a breach of client confidentiality. Currently, persons living where recreational marijuana use is legal must be at least 18 years of age to legally consume. The nurse would not need to ask about where the client obtains the marijuana as the nurse is focused on the client and not other persons. The client has stated marijuana use. How long the client has used marijuana is not important at this time.

A postpartum client asks the nurse when the subdermal hormone implant for contraception can be inserted. How should the nurse respond to this client? A. in 6 weeks B. in 1 month C. 1 week after your next menstrual cycle D. before being discharged after this birth

A The subdermal hormone implant can be placed 6 weeks after the birth of a baby. One month is too soon for the implant to be placed after the birth of a baby. Typically, the rod is inserted during menses or no later than day 7 of a menstrual cycle to be certain that the client is not pregnant at the time of insertion. The implant will not be placed immediately after the birth of a baby.

An adolescent wears a body brace for scoliosis. Which client education should the nurse provide? A. to continue with age-appropriate activities B. to stand absolutely still when not wearing the brace C. to wear the brace a maximum of 20 hours each day D. that secondary sex changes will stop until the brace is removed

A The treatment for scoliosis is aimed at preventing progression of the curve and decreasing the impact on the pulmonary and cardiac function. Bracing is one way to do that. The brace should be worn for 23 hours per day. Wearing a body brace should not interfere with normal activities, which are necessary to maintain adolescent self-esteem. It is extremely important that the adolescent has compliance with the brace usage. The nurse can help by teaching the adolescent ways to help peers understand the need for the brace. Sex changes continue with or without bracing.

The nurse in the emergency department is documenting the appearance and care provided to a victim of rape. Which statement should the nurse include when documenting this care? A. Victim has blood stains on both inner thighs. B. Victim claims to be raped but does not appear fearful or traumatized. C. Victim handling the incident well by talking with the male police officers. D. Victim wearing provocative low-cut lace blouse and bra and short skirt with high heels.

A When documenting the care and condition of a victim of rape, the nurse needs to be certain that statements are accurate and unbiased. The nurse should describe the victim's appearance in unbiased detail, including the presence and location of injuries. Making a statement such as "victim claims to be raped but does not appear fearful or traumatized" is a biased statement. The statement that the victim is handling the incident well by talking with male police officers and using the word "provocative" when describing the victim's clothing are biased statements and should not be a part of the medical record.

A client is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this client? A. oxytocin therapy B. fluid replacement C. pain management D. increasing activity

A With a prolonged descent, intravenous oxytocin may be used to induce the uterus to contract effectively. Fluid replacement, pain management, and activity will not cause the fetus to descend quicker.

Which statement would be most appropriate when explaining endometriosis as a cause of a woman's infertility? A. "Ovulation does take place; however, the misplaced endometrial tissue interferes with transport of the ovum." B. "Your uterine cervix fails to close because it is engorged with tissue." C. "Menstrual sloughing does not occur, so there is never a new base for embryo growth." D. "You do not ovulate because of endometrial implants on the ovaries."

A With endometriosis, endometrial tissue migrates into the fallopian tubes and peritoneum or other sites outside of the uterus. Ovulation occurs, but the egg may be trapped by the misplaced tissue.

A pregnant client at 38 weeks' gestation is to undergo external cephalic version. The client asks the nurse, "What exactly will happen with this procedure?" Which response by the nurse is appropriate? A. "The practitioner will gently press on your abdomen to turn your baby so the head is facing down." B. "Your practitioner will do an ultrasound of your baby to see which direction the head is pointing." C. "The practitioner will insert a catheter into the uterus to add more fluid." D. "The practitioner will apply a soft, disk-shaped cup to the baby's head to help pull the baby out."

A With external cephalic version, the breech and vertex of the fetus are located and grasped transabdominally by the physician's hands on the client's abdomen. Gentle pressure is then exerted to rotate the fetus in a forward or backward direction to a cephalic lie. It is not an ultrasound, but fetal heart rate and possibly ultrasound are checked intermittently. Amnioinfusion involves inserting a catheter through the cervix and into the uterus to add fluid in order to relieve cord compression. With vacuum extraction, a soft, disk-shaped cup is pressed against the fetal scalp and over the posterior fontanel (fontanelle). When vacuum pressure is applied, air beneath the cup is suctioned out and the cup then adheres so tightly to the fetal scalp that traction on the vacuum cord leading to the cup extracts the fetus.

Which factor suggests that a child's disorder is an X-linked inherited one? A. Male children of an affected male are free of the disease. B. Male and female children have the disease equally. C. One of the parents of the child has the disorder. D. The disease will have occurred in a female grandparent.

A X-linked disorders occur only in males. Neither parent will have the disorder; male children of an affected individual will be disease-free because the disease is carried on the X, not Y, chromosome.

An Rh-negative woman at 6 weeks' gestation is scheduled for a medically induced termination. Which outcomes should the nurse identify as appropriate for this client? Select all that apply. A. attended contraceptive counseling B. received Rho(D) immune globulin C. scheduled postprocedure sonogram D. avoided strenuous activity for 3 weeks E. experienced menstrual cycle in 2 months

A, B, C A medically induced termination should be performed within 70 days of gestation. Once the termination medication has been provided, the client should receive Rho(D) immune globulin, schedule a postprocedure sonogram, and attend contraceptive counseling. The client should avoid strenuous activity for 3 days and have a return of a menstrual cycle within 2 to 4 weeks.

The hospice nurse is planning a community program that emphasizes the 2030 National Health Goals to reduce long-term illness and early death in children. Which information should the nurse include in this program? Select all that apply. A. strategies to prevent unintentional injury B. seeking early prenatal care when pregnant C. following recommended immunization schedules D. supporting childhood physical activity expectations E. following recommended dietary intake requirements

A, B, C Nurses can help the nation achieve the 2030 National Health Goals to reduce longterm illness and early death in children by educating women to seek care during pregnancy so that congenital anomalies are less frequent. Another outreach effort would be to teach unintentional injury prevention and the importance of immunizations so unintentional injuries and infectious diseases can be reduced. Physical activity expectations and dietary intake requirements are not strategies to achieve the 2030 National Health Goals to reduce long-term illness and early death in children.

During a routine health checkup, an adolescent expresses concern about pregnancy and sexually transmitted infections. The adolescent states being sexually active. What information can the nurse provide the adolescent? Select all that apply. A. Do not be influenced by friends to have sex. B. If you have intercourse, there is no 100% method to prevent pregnancy. C. Learn about and practice safe sexual techniques. D. Sexual activity does not harm routine physical activity. E. Adolescence is the time when all sexual activitybegins.

A, B, C, D Health teaching guidelines for adolescents regarding sexual activity include not being influenced by friends regarding sex, knowing that there is no 100% method to prevent pregnancy except abstinence, learning about and practicing safe sexual techniques, and sexual activity does not harm physical strength or general wellness. Adolescence is not the time when all sexual activity begins. Sexual activity is an individual activity that is based on level of maturity.

During a routine well-child visit, the mother of a preadolescent client asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male neighbor has been making comments and overtly admiring the child when playing outdoors. What signs of sexual abuse should the nurse tell the mother to look out for? Select all that apply. A. Child reports abdominal pain. B. Child has a change in school performance. C. Child demonstrates anxiety or trouble sleeping. D. Child does not want to be left alone with a certain adult. E. Child spends a great deal of time with peer-group friends.

A, B, C, D Signs of sexual maltreatment include vague reports of abdominal pain, a change in school performance, anxiety or trouble sleeping, and not wanting to be left alone with a certain adult. Spending time with peer-group friends is an expected preadolescent behavior and is not a sign of sexual maltreatment.

The nurse is beginning an assessment to determine a couple's chances of having offspring with genetic anomalies. What should the nurse include in this assessment? Select all that apply. A. age of the female member of the couple B. diseases in the family that span three generations C. ethnic background of both members of the couple D. minimal expression of a previously undiagnosed disorder E. employment status of the male member of the couple

A, B, C, D When conducting a health history assessment in anticipation of genetic counseling, the nurse will assess the age of the female member of the couple because some genetic anomalies are more common in older female clients. The nurse will also assess the couple for diseases that span three generations in both families and will assess the couple's individual ethnic backgrounds. Physical assessment can identify minimal expression of a disorder that has gone previously undiagnosed. Employment status is not typically a part of the health history in preparation for genetic counseling.

The school nurse is preparing an educational session for adolescents to address the 2030 National Health Goals for healthy habits. What should the nurse include in this presentation? Select all that apply. A. abstaining from alcohol B. avoidance of tobacco products C. providing support in times of crisis D. attending college preparation programs E. refusing to participate in substance abuse

A, B, C, E Nurses can help the nation achieve these goals by educating adolescents about the use of cigarettes, smokeless tobacco, alcohol, and substance use disorder and by acting as support people for adolescents during times of crisis to help prevent self-injury or suicide. College preparation programs will not necessarily help adolescents achieve healthy habits.

The nurse is planning an education seminar on safer sexual practices for a group of young adults. Which information should the nurse include in this teaching? Select all that apply. A. Use a latex condom for intercourse. B. Void immediately after having sex. C. Avoid sex with intravenous drug users. D. Hand-to-genital sex is the safest sexual practice. E. Inspect your sexual partner for lesions in the genital area.

A, B, C, E Safer sexual practices include using a latex condom for intercourse, voiding immediately after having sex, avoiding sex with intravenous drug users, and inspecting the sexual partner for genital lesions. Hand-to-genital sex is not the safest sexual practice. Abstinence is the only 100% guarantee against not contracting a sexually transmitted infection.

The nurse instructs a couple on the process of basic fertility testing. Which client statements indicate that teaching has been effective? Select all that apply. A. "The quality of the sperm will be looked at." B. "The sperm will be tested for adequate number." C. "A test will be done to determine if ovulation is occurring." D. "The importance of using in vitro fertilization will be discussed." E. "It will be determined if the sperm and eggs are able to meet correctly."

A, B, C, E There are three parts to basic fertility testing. The sperm are analyzed for number and quality, ovulation is determined, and the environment for the sperm and egg to meet is analyzed. In vitro fertilization is not a part of basic fertility testing.

A male client is considering a vasectomy. Which information should the nurse instruct the client about this procedure? Select all that apply. A. Sexual intercourse can resume in a week. B. The procedure can be done as an outpatient. C. An opioid analgesic will be prescribed for pain control. D. Use a birth control method until a negative sperm reports occur. E. Spermatozoa present in the vas deferens will be viable for 2 weeks.

A, B, D After a vasectomy, sexual intercourse can resume after 1 week. The procedure can be completed as an outpatient. The client may experience a small amount of local pain afterward, which can be managed by taking a mild analgesic and applying ice to the site. An additional birth control method should be used until two negative sperm reports at about 6 and 10 weeks have been obtained. Spermatozoa, which were present in the vas deferens at the time of surgery, can remain viable for as long as 6 months.

A client becomes concerned upon learning for the need to have a karyotype performed. What should the nurse explain to this client about this test? Select all that apply. A. It photographs and displays chromosomes. B. It is a procedure done on all pregnant women. C. It reveals diseases present on chromosomes. D. It can only be done during the first trimester of pregnancy. E. It guarantees that a fetus will not be ill from a genetic disorder.

A, C A karyotype photographs and displays chromosomes and is done to reveal diseases on chromosomes only. A karyotype is not performed on all pregnant women, but only those in which a genetic anomaly is suspected. The karyotype can be performed at any time during gestation and does not guarantee that a fetus will not be ill from a genetic disorder.

A pregnant client tells the nurse that she hopes the baby is not in the breech position because she has heard that this causes difficult labor. What should the nurse include when explaining the reasons for this presentation to the client? Select all that apply. A. multiple fetuses B. maternal diabetes C. fetal birth defects D. lax abdominal muscles E. fetal age less than 40 weeks

A, C, D, E Reasons for the breech presentation include multiple fetuses, lax abdominal muscles, fetal birth defects such as hydrocephalus, and fetal age less than 40 weeks. Maternal diabetes is not identified as a cause for a fetal breech presentation.

The nurse is determining the topics to include in an educational program to meet the 2030 National Health Goals for sexuality and reproductive health. What should the nurse include when planning this program? Select all that apply. A. Outline safer sex practices. B. Discuss the disadvantages of annual mammography. C. Review importance of screening activities. D. Stress the importance of abstinence when teaching adolescent clients. E. Explain the advantages of obtaining the human papillomavirus vaccination.

A, C, D, E The nurse can help the nation achieve the 2030 National Health Goals for sexuality and reproductive health by outlining safer sex practices, teaching about abstinence, underscoring the importance of screening activities such as vulvar and testicular self-examination, and explaining the advantages of obtaining the human papillomavirus vaccination. Annual mammography is not a disadvantage for women of a specific age range.

When assessing a newborn identified genetically as 47XY21+, what can the nurse expect to note on the assessment findings? Select all that apply. A. poor muscle tone B. wide, lower jaw C. palmar crease D. high hair line E. protruding tongue

A, C, E The nurse should recognize this as Down syndrome and the associated clinical manifestations of it as poor muscle tone, palmar crease, and a protruding tongue.

An important concept to teach preschoolers in an effort to prevent attacks of sexual abuse would be to first teach them: A. never to use a restroom at a public beach. B. that their life is their own and they have a right not to have others interfere with it. C. that their body belongs to them and they have the right to decide who can touch it or look at it. D. that they should try and dress modestly even in very warm weather.

C Preschoolers need to learn that they have control of their own bodies as a part of keeping themselves safe.

The nurse is caring for a client who has a retroverted uterus. The nurse would explain that this means her: A. uterus is bent sharply backward at the cervix. B. cervix is located behind the Douglas cul-de-sac. C. entire uterus is tipped backward. D. uterus is anterior to the bladder

C Retroverted means to tip backward; retroversion means to bend backward.

The nurse prepares a couple to have a karyotype performed. What describes a karyotype? A. a blood test that will reveal an individual's homozygous tendencies B. a visual presentation of the chromosome pattern of an individual C. the gene carried on the X or Y chromosome D. the dominant gene that will exert influence over a correspondingly located recessive gene

B A karyotype is a photograph of a person's chromosomes aligned in order.

After an hour of oxytocin therapy, a client in labor experiences headaches and vomiting. What should the nurse do? A. Perform a pelvic examination to assess for full dilation. B. Stop the infusion, then notify the health care provider. C. Urge the client to breathe in and out quickly in succession. D. Administer oxygen via nasal cannula.

B A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. This is first manifested by headache and vomiting. If these danger signs are observed in the client during induction of labor, the nurse will stop the infusion immediately and then report it. Assessing the vagina for dilation, rapid breathing, and administering supplemental oxygen willnot help with water intoxication.

A woman uses a diaphragm for contraception. The nurse would instruct her to return to the clinic to have her diaphragm fit checked after which occurrence? A. cervical infection B. a weight gain of 10 lb (4.5 kg) C. a vaginal infection D. six months of nonuse

B A substantial weight gain or weight loss of 10 pounds (4.5 kilograms) or more may shift the relationship of pelvic organs enough that the diaphragm no longer fits correctly.

A woman calls the clinic to report that she has had some cramping and spotting since the insertion of her IUD three days ago. Which instruction would be most appropriate? A. "Come to the clinic as soon as possible." B. "Consider this normal, because your IUD is newly inserted." C. "Take your blood pressure daily for the rest of the month." D. "You'll have to change your method of birth control."

B A woman may notice some spotting or uterine cramping the first 2 or 3 weeks after IUD insertion. Ibuprofen, a prostaglandin inhibitor, is helpful in relieving the pain.

A 15-year-old adolescent is seen at a health care facility for facial acne. When counseling the teen, the nurse would teach that the basic cause of acne is: A. lack of showering adequately after gym class. B. activation of androgen hormones. C. vitamin deficiency from an inadequate diet. D. thyroid-gland secretions increasing with adolescence.

B Acne occurs in adolescence as the result of hormone influence. With increased androgen production the sebaceous glands become more active. With increased testosterone production (in both boys and girls) increased sebum is produced. These increased hormone productions lead to the development of acne. Showering will certainly lead to cleaner skin and the removal of oils but the lack of showering does not cause acne. Diet and thyroid hormones do not play a role in the development of acne.

Children with acute lymphoblastic leukemia (ALL) may need periodic lumbar punctures. The nurse would teach the parent that this is done to assessfor: A. platelets. B. leukemic cells. C. early meningitis. D. early development of septicemia.

B Acute lymphoblastic leukemia (ALL) is a rapidly progressive cancer affecting the undifferentiated or immature cells. It is the most common form of cancer in children. Throughout the course of the disease and treatment the child will be tested regularly for complete blood counts, bone marrow aspirations, lumbar punctures, and testing for renal and liver function. Lumbar punctures are performed to determine if leukemic cells have infiltrated the central nervous system. Thewhite

Physical neglect of children occurs in various ways. In which family below would you suspect neglect? A. A woman feeds her daughter a total vegetarian diet. B. A father allows his child to stay home from school whenever she chooses. C. A woman worries that immunizations will be painful for her son. D. A father encourages his son to play high school football.

B Allowing children to skip school whenever they desire to do so may be viewed as neglect.

A couple, both age 22, want to know what they can do to improve the chances of conceiving. What should the nurse respond to this couple? A. Have sex every day. B. Have sex every other day. C. Consume a high-fat, low-protein diet. D. The female-superior position is the best for conception.

B Although frequent intercourse may stimulate sperm production, men need sperm recovery time after ejaculation to maintain an adequate sperm count. This is why sex every other day, rather than every day, during the fertile period will probably yield faster results. A diet that is low in fat and moderate in protein is recommended. The male-superior position is the best for conception because the sperm will be closer to the cervical opening

A nurse is teaching a class about puberty to a group of parents with children in middle school. What structure will the nurse identify as the primary regulator of puberty? A. pituitary gland B. hypothalamus C. ovaries D. testes

B Although the pituitary, ovaries, and testes are all involved, the mechanism that initiates this pubertal change is not well understood. It is the hypothalamus, however, that apparently serves as a gonadostat or regulation mechanism to "turn on" gonad functioning. The hypothalamus when triggered sends initial stimulation to the anterior pituitary gland to begin the formation of follicle-stimulating hormone and luteinizing hormone and initiate the process.

The intravenous infusion line infiltrates on a child who is terminally ill, and the child's mother tells the nurse that the nursing care in this hospital is the worst she has ever seen. What is the nurse's best response to her? A. "Tell me with what you are comparing the care here." B. "You seem angrier today than before. Is something going on?" C. "I think you should talk to a nursing supervisor." D. "You're right, but we're trying to improve."

B Anger is a common stage of grief. Recognizing this improves parent- nurse relations and helps the parent work through stages of grief.

After several weeks of caring for a child who is dying, a nurse finds herself hoping that the child will die on the weekend she is scheduled to be off work. This behavior is consistent with which stage of grief? A. acceptance B. bargaining C. anger D. depression

B Bargaining as a stage of grief is making conditions or "deals" to hope to achieve a better outcome.

A child who knows about her terminal disease tells the nurse of plans torecover and become a doctor to cure everyone in the whole world. What is the child demonstrating to the nurse? A. anxiety about the illness B. bargaining stage of grief C. immature magical thinking D. poor opinion of the care received

B Bargaining, a stage of the grief process, is attempting to work out a deal to prevent death from occurring. This child is not demonstrating anxiety, immature thinking, or a poor opinion of the care that has been received.

What is an advantage of a cervical cap over a diaphragm? A. No initial fitting is required. B. It can be left in place longer. C. It needs no spermicidal jelly. D. It does not need to be refitted after pregnancy.

B Because a cervical cap does not press against the sides of the vagina, possibly interfering with blood supply, it can be left in place longer.

The parents of a school-age child are informed that their child has muscular dystrophy and will be wheelchair bound going forward. Which nursing diagnosis should the nurse identify as appropriate for the parents at this time? A. Hopelessness related to steady progression of child's disease B. Interrupted family processes related to recent diagnosis of chronic illness in a child C. Decisional conflict related to treatment options and choice of setting for child's final care D. Risk for delayed growth and development related to lack of age-appropriate stimulation because of disability

B Because the parents are just learning of the diagnosis of muscular dystrophy, this news will interrupt family processes. There is not enough information to determine if the parents are hopeless. The child is not diagnosed with a terminal illness. There is not enough information to determine if the child is at risk for delayed growth and development.

The nurse instructs an adolescent on the hazards of body piercings and tattoos. Which outcome indicates that teaching has been effective? A. The client gets a small tattoo on the inner ankle. B. The client describes the signs and symptoms to report to the provider. C. The client observes a tattoo being done and decides to get one with an older brother. D. The client limits body piercings and tattoos to areas on the trunk.

B Body piercings and tattoos have become a way for adolescents to make a statement of who they are and that they are different from their parents. It is important that they know the symptoms of infection at a piercing or tattoo site (e.g., redness, warmness, drainage, swelling, mild pain) and to report these to their healthcare provider if they occur because serious staphylococcal or streptococcal infections can occur at piercing sites. It is important to caution adolescents that sharing needles for piercing or tattooing carries the same risk for contacting a blood-borne disease as sharing needles for intravenous drug use. Whether or not the adolescent gets a body piercing or tattoo is their choice. But they need to be aware of what to look for if problems arise.

The mother of a toddler experiencing stomach pain insists that the child be admitted to find out the cause of the pain. The child has been in the emergency room three other times in the past 6 months for the same complaint. What other information should alert the nurse to investigate the situation further? A. The mother is a single parent. B. The mother is in nursing school. C. The child has a 1-year-old sister. D. The child verbalizes abdominal pain when the mother is not present.

B Caregiver-fabricated illness (formerly Munchausen syndrome by proxy) refers to a parent who repeatedly brings a child to a health care facility and reports symptoms of illness when the child is well. A parent might report symptoms such as abdominal pain in a child. Because of these symptoms, the child is submitted to needless diagnostic procedures or therapeutic regimens. The parent usually has some degree of medical knowledge or child care knowledge obtained through formal education. Being a single parent, having siblings, and the child verbalizing abdominal pain when the mother is not present are not indications of this syndrome.

The membranes of a client in labor have just spontaneously ruptured. On observing the fetal heart rate monitor, the nurse notes variable decelerations. Which action would the nurse take next? A. Reposition the fetal and uterine monitoring devices. B. Have the client assume a knee-chest position. C. Obtain a sterile urine specimen via straight catheter. D. Prepare the client for an emergency cesarean birth.

B Cord prolapse is usually first discovered after the membranes have ruptured, when the fetal heart rate is discovered to be unusually slow or a variable deceleration fetal heart rate pattern suddenly becomes apparent on a fetal monitor. A prolapsed cord is always an emergency situation because the pressure of the fetal head against the cord at the pelvic brim leads to cord compression and decreased oxygenation to the fetus. Management is aimed, therefore, at relieving pressure on the cord, thereby relieving compression and the resulting fetal anoxia. This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord, or by placing the woman in a knee-chest or Trendelenburg position, to cause the fetal head to fall back from the cord. Repositioning the monitoring devices, obtaining a urine specimen, or preparing for a cesarean birth would be inappropriate.

The nurse is assessing the health history of a male partner. Which data is most likely to be related to an infertility problem? A. 30 years of age B. employment as a taxi driver C. intercourse approximately every third day D. immunization against mumps as a child

B Excessive testicular heat, which can occur from long periods of sitting, can limit sperm production and mobility.

A nurse is providing care to a woman who is to undergo surgery to remove fibroid tumors. The nurse teaches the woman about the procedure and what to expect after it. The nurse determines that the teaching was successful whenthe woman identifies which situation as most likely to occur after the surgery? A. treatment with a testosterone B. insertion of an intrauterine device C. recommendation to become pregnant immediately D. counseling to accept child-free living

B Following uterine surgery, an IUD may be placed to prevent adhesions from forming and reducing the size of the cavity. The woman may be prescribed estrogen, not testosterone, for 3 months as another method to prevent adhesion formation. This treatment can be difficult for a woman to accept because preventing pregnancy (using an IUD) is exactly what she does not want to do. Be certain she has a good explanation of the IUD's purpose and that it can be easily removed in about 1 month's time.

A parent asks the nurse what the philosophy or purpose of a hospice program is. What is the nurse's best response? A. "A hospice is a facility that provides long-term care." B. "A hospice provides care with the belief that death is an extension of life." C. "A hospice allows for open visiting and homelike care." D. "A hospice is a facility for the terminally ill."

B Hospices not only provide care for people who are dying, but also individualize care to make it an extension of the person's life.

A prenatal ultrasound reveals that a pregnant client has vasa previa. Which action by the nurse is appropriate? A. Tell the client to come to the labor and birth suite as soon as labor begins. B. Explain to the client about the need for a scheduled cesarean birth. C. Expect that an oxytocin infusion will be needed to augment labor. D. Anticipate the need for the use of forceps during the birth process.

B In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and, therefore, deliver before the fetus. The vessels may tear with cervical dilation (dilatation), just as a placenta previa may tear. Tearing would result in sudden fetal blood loss. Therefore, if the vasa previa is identified prenatally on ultrasound, a cesarean birth is scheduled prior to full term to prevent risks of spontaneous labor. Waiting until labor begins would increase the pregnant client's risk for vessel tearing. Neither oxytocin nor forceps would be used.

Which definition best explains the term "subfertility/infertility"? A. failure to achieve pregnancy after 6 months of unprotected intercourse B. failure to achieve pregnancy after 1 year of unprotected intercourse C. inability to achieve pregnancy because of a known factor that prevents conception D. inability to achieve pregnancy following a previous viable pregnancy

B Infertility is the failure to achieve conception after 1 year of unprotected intercourse. Because most couples have the potential to conceive but are just less able to conceive without additional help, the term subfertility is more often used today.

The parents of an infant newly diagnosed with an X-linked dominant inheritance disorder are asking questions to increase their understanding of the disorder and how it may affect future offspring. Which information is most important to explain to the parents to answer their questions? A. It only affects male offspring. B. It appears in every generation. C. All children of the couple will be affected. D. Diseases caused by this disorder are not life-threatening.

B It is common for parents to be overwhelmed with education when an infant is newly diagnosed. When addressing future offspring, it is important to teach how the X-linked dominant inheritance disorders appear in every generation. The pattern of inheritance is through the X chromosome and affects female offspring. Not all children will be affected. It is unclear if the diseases caused by this disorder are life threatening.

A number of inherited diseases can be detected in utero by amniocentesis. Which disease can be detected by this method? A. diabetes mellitus B. trisomy 21 (Down syndrome) C. phenylketonuria D. impetigo

B Karyotyping for chromosomal defects can be carried out using amniocentesis.

When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would be to: A. turn her to her left side. B. place her in a knee-chest position. C. replace the cord with gentle pressure. D. cover the exposed cord with a dry, sterile wrap.

B Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the woman in a knee-chest position accomplishes this. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels.

The parents of a terminally ill child do not want the child dying in thehospital. What can the nurse suggest to help the parents' needs? A. Admit to a long-term care facility. B. Have hospice provided through home care. C. Discharge the child to home right before death. D. Have family stay with the child around-the-clock in the hospital.

B Many families prefer that a child die at home, surrounded by family and familiar possessions, rather than in a hospital. For many children, hospice care is furnished as part of home care, so that they are not separated from their families. This would be the best suggestion for the nurse to make to the parents of the dying child. A long-term care facility is similar to a hospital and would not meet the family's needs. Discharging the child to home prior to death will not meet the needs of the family. Having the family stay with the child around-the-clock in the hospital definitely will not meet the family's needs.

The nurse is planning care for a preschool-age child diagnosed with bacterial meningitis. What should the nurse identify as a priority goal for this client's care? A. Inspect the teeth for obvious caries. B. Reduce the pain related to nuchal rigidity. C. Provide an opportunity for therapeutic play. D. Increase stimulation opportunities to prevent coma.

B Meningitis is an infection of the cerebral meninges. Pathologic organisms spread to the meninges. Once organisms enter the meningeal space, they multiply rapidly and then spread throughout the CSF to invade brain tissue through the meningeal folds, which extend down into the brain itself. A child with meningitis usually has an upper respiratory tract infection prior to the development of meningitis. Then the child will become increasingly irritable because of an intense headache with sharp pain when bending the head forward. Reducing the pain caused by neck pain would be the priority goal for this client's care. Inspecting the teeth, providing opportunities for play, and increasing stimulation would not be priority goals for this client.

The nurse is providing education on adolescent safety to a group of caregivers.Which statement by a caregiver indicates additional teaching is needed? A. "Teenagers should not cook on the stove when home alone." B. "Taking a course on driving safety is sufficient to teach safe driving skills." C. "Firearms should be kept in locked boxes, closets, or cabinets." D. "Setting limits is beneficial when rearing teenagers."

B Motor vehicle accidents are the number one cause of death in adolescents. Taking one course on safe driving is not enough to ensure safe driving skills are mastered by a new driver. Adolescents should not cook on the stove or in the oven when home alone to limit fire risks. Firearms should be kept in a locked area, where children do not have access. Limits, such as curfews, are beneficial during the adolescent years.

A 1-year-old is a victim of child abuse (child maltreatment). Which factor obtained on history is most apt to be associated with the risk of medical child abuse (formerly Munchausen syndrome by proxy) in children? A. The family has a low socioeconomic level. B. The mother was abused as a child. C. The parents are outgoing, gregarious people. D. The family is an extended one.

B Parents tend to parent the same way as their parents. Abuse, therefore, continues from generation to generation.

The nurse decides to spend extra time with a pregnant client in the prenatal clinic in an effort to determine if the client is a victim of intimate partner violence. What caused the nurse to make this plan prior to assessing the client? A. She is chatting with another client in the waiting room. B. The client is wearing a long-sleeved jacket on a hot summer day. C. The client is periodically looking at her watch to check the time. D. The client is unconsciously rubbing her abdomen while reading amagazine.

B Pregnant maltreated patients may demonstrate typical behaviors that reveal violence. A client may dress inappropriately for warm weather, wearing long- sleeved blouses to cover up bruises on the neck or arms. A pregnant woman talking with another client, checking the time on her watch, or rubbing her abdomen while reading a magazine are not behaviors that indicate intimate partner violence.

While making a home visit, the nurse suspects that a child is experiencing psychological maltreatment. What did the nurse observe in the home? A. scolding one child for playing with matches B. belittling the child in front of the nurse and other siblings C. punishing one child for crossing the street without assistance D. asking one child to perform a song on the piano for the nurse

B Psychological maltreatment includes constantly belittling a child. Children who are psychologically maltreated this way are likely to have difficulty becoming emotionally confident adults. This type of maltreatment is the most difficult form of maltreatment to detect because it may occur only in the home. Scolding for using matches, punishment for crossing the street without assistance, and asking to perform a song on the piano are not observations that support psychological maltreatment.

Which information is important for a woman to understand before undergoing a scheduled tubal ligation? A. She will have lessened dysmenorrhea following the procedure. B. She must think of the procedure as irreversible. C. The procedure will reduce her menstrual flow in amount. D. She should schedule it to be done just before a menstrual flow.

B Sterilization by fallopian tube obstruction does not alter menstrual symptoms or flow. Ectopic pregnancy could result if it is done following ovulation; reversing the process is difficult.

Which intervention would probably be most effective in preventing an adolescent from attempting suicide with an overdose again? A. Assessing financial situation B. Helping to learn better problem solving C. Teaching the parents to keep medicine in a locked cabinet D. Helping to locate a close friend atschool

B Suicide is a solution when there does not appear to be any other solution. Suicide rates increased by 58% among 10-24 years of age between 2016- 2018 (CDC 2020) and is so common in adolescents that it ranks as the 2nd causes of death in the 15- to 19-year-old age group. Some of the risk factors for suicide include a history of a previous suicide attempt, substance use disorder, depression, poor school performance, and family disorganization. Helping an adolescent learn better problem solving can help prevent a second attempt. Keeping medications locked may be a good safety practice but it does not solve the adolescent's depression and the underlying reason the adolescent feels the need to commit suicide. The financial level is not indicative of a need to commit suicide. Suicide can occur in all socioeconomic levels. The adolescent who is alone and has no close friends at school is at higher risk for suicide. Helping the adolescent find a friend would be a positive action but it is not as important as helping the teen to make better choices and have better problem-solving skills.

The nurse is explaining the procedure of bone marrow aspiration to a 6-year-old child with leukemia. What explanation would be best to give to the child? A. "You will need to lie still afterward to prevent a headache." B. "You may feel pressure on your hip during the procedure." C. "You will have to lie on your back and hold your breath." D. "The numbing medicine on your skin will keep you from having pain."

B The bone marrow aspiration is performed on the iliac crest if the child is older and on the femur if the child is an infant. Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. A lidocaine/prilocaine cream is applied to the skin anywhere from 1 to 3 hours prior to the procedure to help numb the site where the needle will be inserted. Bone marrow aspirations and biopsies are usually performed with conscious sedation. If the child is an infant or there are special circumstances the procedure may be performed under anesthesia. The child is placed on the side for the procedure so the health care provider has better access to the iliac crest. The child will need to rest after the procedure to prevent bleeding, but is not required to lay flat on the back. Children who have had a lumbar puncture may need to lie on the back and are at risk for a headache.

A pregnant client in labor is having contractions about 4 minutes apart but rarely higher than 20 mm Hg in strength with resting tone ranging from 5 to 8 mm Hg. The client asks what can be done to make contractions more effective. How will the nurse respond to the client? A. "Get some rest, because the contractions are hypertonic." B. "You may need oxytocin to strengthen contractions." C. "Relax, because contractions of this kind will strengthen by themselves." D. "Try sitting up a little more erect to make the contractions more regular."

B The client is experiencing hypotonic contractions which are often helped with the administration of oxytocin. Such contractions may or may not begin to strengthen on their own. Additionally, telling the client to relax ignores the client's concerns. Resting would be appropriate for hypertonic contractions. Sitting up will not help make the contractions more regular.

A nurse is working with a woman who is using the calendar method to determine her safe days. The nurse would instruct the woman to subtract: A. 14 from 28. B. 18 from her shortest period and 11 from her longest. C. The length of her average period from the ideal of 28. D. 18 from the longest period and 11 from her shortest.

B The days surrounding ovulation (3 days before and 3 days after) are the most fertile days. To plan, the woman keeps a diary of about six menstrual cycles. To calculate "safe" days, she subtracts 18 from the shortest cycle she documented. This number predicts her first fertile day. She then subtracts 11 from her longest cycle. This represents her last fertile day. If she had six menstrual cycles ranging from 25 to 29 days, her fertile period would be from the 7th day (25 [the shortest cycle] − 18) to the 18th day (29 [the longest cycle] − 11). To avoid pregnancy, she would avoid sex during those days.

A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse teach the child about the purpose of the brace? A. prevents torticollis B. improves spinal stability C. corrects existing spinal curvature D. prevents herniation of a spinal disk

B The goal of mechanical bracing is to maintain spinal stability and prevent further progression of the deformity until bone growth is complete. Bracing will not prevent torticollis, correct the curvature, or prevent herniation of a spinal disk.

If one of the parents of a child who has been abused is found to be the abuser, what would the nurse implement as a long-term intervention for that parent? A. returning to school for mandated parenting classes B. participating in an organization such as Parents Anonymous C. placing the child in a home with a relative until parents are capable of handling a child D. seeking intensive psychotherapy to gain a better understanding of why abuse is occurring

B The organization Parents Anonymous can be very helpful to parents who are potential or actual abusers.

An adolescent admits to using marijuana on a daily basis. What should thenurse explain to the client to help improve performance in school? A. The effect of marijuana fades fastest if eating occurs after use. B. Marijuana causes memory gaps that interfere with learning. C. Marijuana leads to muscle laxness, so it should not be used close to gym class. D. Marijuana increases blood pressure; running should not be done after smoking it.

B The products of marijuana are not readily eliminated from the body but remain in the fatty cells of the brain. This residue can create synaptic gaps that interfere with electrical brain waves and memory storage, especially for short-term memory. This will affect learning. The effects of marijuana do not fade faster if eating occurs after use. Marijuana use is not linked to physical performance or blood pressure.

The nurse caring for children on a pediatric oncology floor delays entering some of the children's rooms unless providing medication or performing a procedure. Which stage of the grieving process is influencing this nurse's ability to provide client care? A. anger B. denial C. bargaining D. depression

B There is a danger that a nurse who is in a stage of denial may care for children by avoiding going into a child's room unless an important procedure must be done. Nurses who are angry might provide care that is sharp and abrupt. Bargaining is promising to do something in exchange for the child not dying. Nurses who are in the depression stage may be ineffective caregivers because problem-solving and decision-making become a chore.

A 40-year-old woman who smokes desires a reliable contraceptive method. Which should the nurse recommend to this client? A. an ovulation suppressant B. a condom and spermicide C. a spermicidal suppository D. the rhythm (calendar) method

B Women who are 40 years of age and smoke should not take ovulation suppressants. Irregular menstrual cycles make natural methods difficult. Women older than the age of 40 may have vaginal dryness, so a spermicidal suppository would not be effective. The best option is for the client to use a condom and spermicide.

The fetal heart rate patterns of a pregnant client in labor revealsvariable decelerations. Which nursing action(s) is appropriate? Select all that apply. A. Insert an intravenous catheter to initiate an infusion of oxytocin. B. Assist with amnioinfusion of warmed normal saline. C. Administer supplemental oxygen via a nonrebreather mask. D. Assist the client to change position at frequent intervals. E. Prepare the client for a cesarean birth.

B, C, D If a fetal heart rate is showing variable decelerations—an indication that there is cord compression—an amnioinfusion may be started. Additionally, oxygen should be applied via a nonrebreather mask and position changes for the pregnant client are likely necessary. If the client has IV oxytocin, the infusion should be stopped. The client may also need a tocolytic to stop contractions so the pressure on the cord can be relieved. Many times with these resuscitation maneuvers, labor can continue and the client can proceed with a vaginal birth.

The school district is planning an educational program for high school students to reduce the incidence of rape. When planning this program, which information should the school nurse include? Select all that apply. A. Carry a weapon or mace at all times. B. When leaving school after dark, walk on the street. C. Lock car doors when waiting in it and after parking it. D. Keep all doors and windows locked when home alone. E. Avoid taking illegal substances when in social situations.

B, C, D, E Guidelines to prevent rape in adolescents include walking on the street when it is dark, locking car doors when waiting in it and after parking it, keeping all doors and windows locked when home alone, and avoid talking illegal substances such as flunitrazepam (Rohypnol) when in social situations. Students should be cautioned about carrying weapons or mace because these items can be used against them.

A client in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will be used. What should the nurse do to prepare the client for this type of delivery? Select all that apply. A. Provide oxygen 2 L via face mask. B. Validate that the cervix is fully dilated. C. Determine that the client's bladder is empty. D. Begin an intravenous infusion of replacement fluid. E. Ensure that the client's membranes have ruptured.

B, C, E Prior to using forceps for delivery, the cervix must be fully dilated, the client's bladder must be empty, and the client's membranes must have ruptured. The client does not need oxygen for a forceps delivery. The client does not need an intravenous infusion prior to forceps delivery.

The nurse is caring for a child diagnosed with scoliosis. What actions by the child would indicate a need for intervention by the nurse? Select all that apply. A. placement of the brace over a t-shirt B. removal of the brace at bedtime C. Reports of, "I feel taller with the brace on." D. Loosening of the straps on the brace prior to bedtime. E. removal of the brace while playing a soccer game

B, D The placement of the brace over a t-shirt helps to prevent skin excoriation. The brace should only be removed 1 hour a day, during showering and participating in a sports activity. Straps should never be loosened on the braces. Children may state they feel taller with the brace on

An 18-month-old is brought to the emergency room by her babysitter. The babysitter states, "She fell from the sofa an hour ago and has not been herself since." Upon questioning, the babysitter appears to be unsure of time and other facts about the incident. Which of the following questions would be most effective in obtaining more information about the child's injuries A. "Why did you leave the baby alone on the couch?" B. "Have you taken a course in safe babysitting?" C. "Tell me what was happening before she fell." D. "Where are her parents? Do they know this happened?

C An open-ended question is apt to supply more information when a person is under stress and easily susceptible to being influenced by the question.

A 16-year-old girl who has been confined to a wheelchair since early childhood has been acting rebellious and rude. Her parents ask the nurse, "Are all adolescents like this?" What is the nurse's best response? A. "Yes. Although your daughter's behaviors are more like those of an adolescent boy." B. "No. Your daughter must need some help in dealing with her feelings." C. "Your daughter's behavior seems to be typical adolescent behavior. Let'stalk more about it." D. "Your daughter's behavior results from feelings about her disability; ignorethem."

C As adolescents strive to separate from parents, a period of stress and turmoil can result. Frank discussion can clear the air and help bring resolution.

Which statement by a parent of a 4-year-old child is most likely to suggest child abuse (child maltreatment)? A. "He is constantly on the go." B. "He has his father's eyes." C. "He doesn't ever help me clean house." D. "He doesn't seem to like strangers."

C "Role reversal," or a child taking care of a parent, is frequently seen with child abuse.

After delivery, a client is diagnosed with placenta succenturiata. For what procedure should the nurse prepare this client? A. lavage of the uterus B. repair of an episiotomy C. manual removal of accessory lobes D. emergency resuscitation of the newborn

C A placenta succenturiata is a placenta that has one or more accessory lobes connected to the main placenta by blood vessels. This disorder needs to be recognized because the small lobes may be retained in the uterus after birth, leading to severe maternal hemorrhage. Once the remaining lobes are recognized and removed from the uterus manually, the uterus will contract with no adverse maternal effects. Uterine lavage is not a treatment for this disorder. This disorder is not specifically associated with an episiotomy. No fetal abnormality is associated with this disorder.

A client is diagnosed with a uterus that is slightly retroverted. When discussing the implications of this finding, what should the nurse include? A. This finding indicates the need for surgery. B. This finding will render the client infertile. C. This finding should not cause fertility issues. D. This finding could interfere with conception.

C A retroverted uterus means the uterus tips back. Minor variations of these positions do not tend to cause reproductive problems. A retroverted uterus does not mean that the client needs surgery. A retroverted uterus does not interfere with fertility. The only way that a retroverted uterus will interfere with conception is if the abnormal position is extreme because the sharp bend can block the deposition or migration of sperm.

What activity would best foster the developmental task of an adolescent who uses a wheelchair to ambulate? A. Allowing the adolescent to decide when to bathe B. Watching television on the set in the adolescent's room C. Talking to another adolescent who has a similar situation D. Having a teacher bring school work to the adolescent

C A sense of identity is developed by "trying on" roles and discussing values and goals with others. A sense of trust develops when an adolescent is able to find out whom (and what ideas) to have faith in. The adolescent period is also a time where past stages of development are revisited. The sense of autonomy is where the adolescent seeks ways to express individuality. The stage of initiative is where the adolescent develops vision of what he or she might become. Talking with another adolescent who also uses a wheelchair to ambulate will help the adolescent see possibilities and reassurances. Making decisions or having assistance from someone else does not allow the adolescent to "try out" roles.

20. The nurse visits the foster home of a newborn with failure to thrive syndrome.Which observation indicates a successful outcome for this child's care? A. Birth mother has stopped visiting the child. B. Birth father comes by the home to bring toys. C. Child eagerly takes a bottle and is gaining weight. D. Child is crying and has bruises over the lower legs.

C A successful outcome for the care of a child with failure to thrive syndrome would be that the child shows interest in bottle feedings and begins to gain weight. The child crying and having bruises over the legs could indicate physical abuse or another medical problem. The mother not visiting the child indicates ongoing psychological issues with the mother bonding with the child. The father bringing toys does not indicate that the care of the child has been successful. The father's bonding with the child cannot be determined by this action of bringing toys.

During a health visit, an adolescent client tells the nurse, "Why am I having all thisacne?" Which response by the nurse would be appropriate? A. "Your thyroid gland is secreting more hormones as you grow." B. "Your acne is most likely from not keeping your skin clean enough." C. "Your body is producing hormones called androgens that are responsible for your acne." D. "You must have a vitamin deficiency because you're not eating healthy."

C Acne is a self-limiting inflammatory disease that involves the sebaceous glands, which empty into hair shafts. One cause for the development of acne is an increase in androgen levels, which cause sebaceous glands to become active. Acne is not caused by thyroid gland secretions. Acne does not develop because of poor personal hygiene; although, poor hygiene can make acne worse. Acne is not caused by a vitamin deficiency.

An adolescent is concerned that he is going to be unusually short. The nurse would advise him that the epiphyseal lines of long bones in boys that govern growth usually close between ages: A. 13 and 14 years. B. 14 and 15 years. C. 17 and 18 years. D. 20 and 22 years.

C Although the end of skeletal growth is variable, it ends in most boys between 17 and 18 years of age.

The nurse is caring for an infant born with a congenital anomaly. Which of the following factors is likely to have the most influence on the mother's ability to cope with the infant's handicap? A. the mother's age B. the gender of the infant C. the parents' amount of support D. the fact that this is a mental and not a physical challenge

C Availability of support people to help the mother cope with the infant's handicap will have a major influence. A family that has few close friends and lives some distance from relatives is apt to have more difficulty adjusting to illness in a child than a family that has close support people. People who can locate secondary support systems in their community usually do better than parents who are without these resources. The mother's age, gender of the infant, and type of handicap will not have the most influence on the mother's ability to cope with the infant's needs.

An infant with nonorganic failure to thrive stares at the nurse constantlywhile she cares for her. This is probably occurring as a result of: A. poor vision from vitamin deficiency. B. potassium deficiency from an inadequate diet. C. previous lack of stimulation. D. searching for her mother from loneliness.

C Because the child has not enjoyed a close relationship, he or she seems "hungry" to interact with a person who shows interest.

A client decides to use the cervical mucus method as her contraceptive method. When describing this method, the nurse explains that the client can determine ovulation based on which characteristic of the mucus? A. thick consistency with clumping B. acidic odor and slightly yellow color C. thin and slippery D. transparent with the odor of eggs

C Before ovulation each month, the cervical mucus is thick and does not stretch when pulled between the thumb and finger. Just before ovulation, mucus secretion increases. On the day of ovulation (the peak day), it becomes copious, thin, watery, and transparent. It feels slippery (like egg white) and stretches at least 1 inch before the strand breaks, a property known as spinnbarkeit.

An adolescent shares with you that she wishes her breasts would grow larger. Which initial nursing response is best? A. "It is unlikely that your breasts will grow any more. I wouldn't spend time thinking about it." B. "You look fine to me. Why would you want larger breasts?" C. "Breast growth usually stops by the age of 16 years. What is the reason you were hoping yours would grow more?" D. "Let's talk about your concern. You know that breast size has nothing to do with ability to reproduce."

C Beginning with the facts is appropriate. It is not unusual that many adolescents are disappointed about their physical appearance. Helping them talk about this helps them work through their feelings and reestablish self-worth. Statements to not "think about it" or "not having an impact on reproduction" close communication. Stating that the client looks fine to the nurse may be kind but is inappropriate and closes communication

The nurse is caring for a child with Down syndrome (trisomy 21). This is an example of which type of inheritance? A. Mendelian recessive B. Mendelian dominant C. chromosome nondisjunction D. phase 2 atrophy

C Down syndrome occurs when an ovum or sperm cell does not divide evenly, permitting an extra 21st chromosome to cross to a new cell.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor? A. Hold all explanations until after the birth to conserve the woman's energy. B. Limit discussing things the woman asks questions about. C. Provide ongoing communication about what is happening. D. Tell her not to feel anxious or discouraged about what is happening.

C Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

Which action would provide an indication that an adolescent's parents understand their child's need for increased independence? A. Verbalizing, "We try to do everything we can to make things easier for her." B. Reporting they understand that their child's chief need is for increased privacy C. Stating they are encouraging their child in the search for an after-school job D. Saying, "We will always be here for her whenever our child needs us."

C Encouraging adolescents to separate from parents, not to continue to rely on them, can be difficult for parents because it involves allowing adolescents to face and solve problems instead of having them solved for them. Fluctuating relationships with parents may limit the teen from seeking assistance with the common issues of the teenage years. The adolescent years are full of unpredictability and inconsistencies. When the parents are aware of the teen's need for developing independence it provides the teen with stability. Making things easier and always being available make the teen more dependent on the parents instead of developing independence.

A man needs to bring a semen specimen in for analysis. Which instruction would the nurse give him? A. Obtain it immediately after voiding. B. Collect it immediately after sex. C. Protect it against chilling. D. Dilute it with saline for transport.

C Extremes of body temperature (hot or cold) interfere with sperm viability.

A woman telephones the nurse after taking an ovulation suppressant for 3 months to state that she has forgotten to take her pill two mornings in a row. What would be the best adviceto give her regarding this? A. Start a new cycle of 21 pills immediately plus additional estrogen for the next 3 days. B. Take three pills immediately and avoid sex for the remainder of the month. C. Take two pills now and use a second method of contraception for the remainder of the month. D. Take two pills a day for the rest of the month.

C Failure to take two pills could have resulted in ovulation, so additional protection should be used for the remainder of the cycle.

A 3-month-old infant is diagnosed with failure to thrive. For which cause should the nurse include interventions when planning care for this client? A. a reaction to severe stress B. limited calcium metabolism C. poor parent-child relationship D. interference with gastrointestinal absorption

C Failure to thrive is a syndrome in which an infant falls below the 5th percentile for weight and height on a standard growth chart or is falling in percentiles on a growth chart. One category of this syndrome occurs because of a disturbance in the parent-child relationship, resulting in maternal role insufficiency or a nonorganic cause. Failure to thrive is not caused by a reaction to severe stress, limited calcium metabolism, or interference with gastrointestinal absorption.

A 4-year-old child has developed acute lymphoblastic leukemia (ALL). Nursing care for the child with ALL involves taking axillary, rather than rectal, temperatures because the child: A. is anemic. B. has a low white blood cell count. C. has a low platelet count. D. is prone to diarrhea.

C In ALL, the bone marrow becomes unable to maintain the normal levels of red blood cells, white blood cells, and platelets. Children with ALL bruise and bleed easily. If a rectal thermometer is inserted it can cause bleeding from the irritation of the mucosal membrane because of the decreased platelet count. Using a rectal thermometer also is invasive so there is a large possibility of introducing microorganisms to the child. This could be damaging to the child if the child is neutropenic and has no immune defenses. The child may be prone to diarrhea because of the chemotherapy drugs but that is not the primary reason for not using the rectal temperature. Nursing care for the child should also be provided in the least invasive manner possible. That means not using any IM or SQ injections.

The nurse is meeting with a young couple who have undergone the initial screenings for infertility. The man is questioning the possibility of using intrauterine (artificial) insemination if he is found to be infertile. Which response should the nurse prioritize? A. "Intrauterine (artificial) insemination is a possibility but there is the increased chance of twins." B. "Intrauterine (artificial) insemination is useful only if your sexual partner has an allergy to your sperm, not if you are infertile." C. "Intrauterine (artificial) insemination is your best option if you are found to be infertile." D. "You and your sexual partner should consider embryo transfer first because it is safer."

C Intrauterine (artificial) insemination involves the donation of sperm from another fertile male; it is used when the primary sexual partner is infertile. Intrauterine (artificial) insemination does not increase the risk of multiple gestations; that occurs with in vitro fertilization. Intrauterine (artificial) insemination is not used for allergies. Embryo transfers are not the first choice in cases of infertility.

The nurse is caring for a 4-year-old with meningitis. A primary nursing goal would be to: A. increase stimulation opportunities to prevent coma. B. provide an opportunity for therapeutic play. C. reduce the pain related to nuchal rigidity. D. inspect the teeth for obvious caries.

C Irritation of the meninges causes pain on forward flexion of the neck.

A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action? A. "Be careful; you'll hurt the doll that way." B. "Are you playing a game from television?" C. "What are the dolls doing?" D. "Nice dolls don't do that. Why are you playing that way?"

C It is easy to lead children into supplying answers they think are the ones wanted. An open-ended question does not suggest an answer.

An 18-month-old child is admitted with signs of increased intracranial pressure.What should the nurse observe when assessing this client? A. numbness of fingers and decreased temperature B. increased pulse rate and decreased blood pressure C. increased temperature and decreased respiratory rate D. decreased level of consciousness and increased respiratory rate

C Manifestations of increased intracranial pressure include increased body temperature and decreased respiratory rate. Pulse rate slow and blood pressure increases.

The nurse is identifying outcomes for an adolescent client who has been avoiding bread products and grains in order to lose weight. Which outcome should the nurse identify as appropriate for this client's nutritional needs? A. The client will ingest bread and grain products during breakfast. B. The client will have no further signs of calcium, iron, and zinc deficiency. C. The client will have no further signs of thiamine and riboflavin deficiency. D. The client will ingest bread and grain products when eating out with high schoolfriends.

C Many adolescents omit breads and cereals entirely to lose weight rather than just reducing the amounts they eat. Diets such as these can be deficient in thiamine and riboflavin, vitamins necessary for growth. The outcome in which the adolescent is without signs of thiamine and riboflavin deficiency would be appropriate for this client. The outcome where the client ingests bread and grains with breakfast might not be sufficient for the adolescent's growth needs. The outcome that focuses on calcium, iron, and zinc deficiency would be appropriate if the adolescent avoids eating meat, milk products, and green vegetables. The outcome where the client ingests bread and grain products with high school friends might not be a sufficient amount to meet the growing adolescent's health needs.

A terminally ill school-age child is awake at 2 AM and continues to put on the call light. What should the nurse do regarding this child's behavior? A. Provide the child with a sleeping aid. B. Encourage the child to sleep. C. Sit with the child until sleep comes. D. Put on the television and dim the lights.

C Many children assume that they will die at night. A child may talk more freely at night about fears or an unfulfilled life ambition than during the day. Children may also be more frightened at night and enjoy having someone sit beside them until they fall asleep. The nurse should not provide the child with a sleeping aid. Encouraging the child to sleep will not meet the child's needs at this time. Putting on the television with dim lights in the room will not meet the child's needs at this time.

The responsibility of the nurse caring for a victim of child abuse (child maltreatment) in the emergency room would include which of the following? A. prohibiting parents from visiting until more facts are obtained B. prohibiting the babysitter from staying to offer support C. suggesting to the attending physician that the child be admitted for observation D. asking the child what was happening that led to the abuse

C Nurses are responsible for seeing that abused children are protected from further abuse and that the abuse is reported.

A nurse is teaching a woman how to use the basal body temperature method of contraception. the nurse determines that the teaching was successful when the woman identifies that she should refrain from having sexual intercourse at which time? A. 4 days after she notices her temperature rise. B. 7 days after noting a slight increase followed by a dip in her temperature. C. 3 days after she records a slight drop in her temperature followed by an increase. D. 14 days after the last day of her menstrual period.

C Ovulation occurs after a slight drop in temperature followed by an increase. The ovum has a life span of 3 days. As soon as a woman notices a slight dip in temperature followed by an increase, she knows she has ovulated. She refrains from having coitus (sexual relations) for the next 3 days (the possible life of the discharged ovum).

A nurse is teaching a couple about how to use a condom. The nurse determines the couple can properly apply the condom when they state that it should be applied at which time to be most effective? A. as part of foreplay B. at least 1 hour prior to sex C. before penile-vulvar contact D. immediately after ejaculation

C Some sperm may be released with pre-ejaculation semen, so a condom needs to be used with any penile-vulvar contact. It is best applied when the penis is erect. It is not necessary to apply an hour in advance. Waiting until after ejaculation would not be effective. It can be part of the foreplay; however, the primary goal is to prevent sperm from entering the vagina, so it should be in place before any penile-vulvar contact occurs.

Which nursing action will best assist a 15-year-old client accomplish the developmental task according to Erikson? A. Permit the client to make decision regarding one's care B. Praise the client for correctly performing self-care C. Allow the client's friends to visit while the client is hospitalized D. Provide the client with crafts and puzzles to complete independently

C The developmental task of adolescence is to develop a sense of identity, or deciding who and what kind of person one is. Friends and peers are important to facilitating the adolescent in determining one's identity. Permitting the client to make decisions assists in developing autonomy, which is a toddler task. Praising facilitates initiative, which is a preschool task. Independently performing tasks assists in developing industry, which is a school-age task.

An adolescent comes into the emergency department with a foot wound. Upon assessment, the nurse learns that the client is a runaway and has been living on the streets. Which is the most appropriate care for the nurse to provide to the client at this time? A. Recommend returning to live with parents. B. Treat the wound and provide wound care supplies. C. Discuss the importance of a diet high in protein and vitamin C. D. Explain how the wound needs to be flushed with water every 4 hours.

C The nurse is not aware of the adolescent runaway's family situation so suggesting returning home with parents may or may not be appropriate. Because the adolescent runaway has no money for any kind of food, giving instructions to eat foods high in protein and vitamin C makes no sense. If the adolescent runaway does not have a source of running water, telling them to flush the wound with water every 4 hours will be impossible. The best care at this time would be for the nurse to treat the adolescent runaway's wound and provide them with wound care supplies.

A nurse should instruct a client who has a very low sperm count to make whichlifestyle modification? A. Have intercourse every other day. B. Have intercourse only once a month. C. Abstain from intercourse for 8 days at a time. D. Abstain from intercourse for 15 days at a time.

C The nurse should advise the client to abstain from intercourse for 7 to 10 days at a time to increase sperm counts.

Which of these findings should a nurse investigate first when assessing a female client who has been unable to conceive for 14 months? A. The client has been female circumcised. B. The client experienced a miscarriage 3 years ago. C. The client was diagnosed with thyroid cancer 2 years ago. D. The client takes a daily folic acid supplement.

C The nurse should further assess the extent of the thyroid cancer as endocrine dysfunction can be a significant source for infertility.

After assessing a client, a nurse determines that an IUD as a method of contraceptive would be contraindicated based on a history of which finding? A. Smoking B. Hypertension C. Abnormal uterine shape D. Thromboembolic disease

C Use of an IUD may be contraindicated for a woman whose uterus is distorted in shape (the device might perforate the uterine wall). The copper IUD use also is not advised for a woman with severe dysmenorrhea (painful menstruation) or menorrhagia (heavy bleeding) because use may increase the incidence of these conditions. Because use of a copper IUD can cause heavier than usual menstrual flow, a woman with anemia also may not be considered a good candidate for a copper IUD. The other findings are not contraindications.

An adolescent is prescribed retinoic acid cream as therapy for his acne. About which of the following would you caution him? A. not putting the medication on just prior to bedtime B. applying the cream while his face is wet C. avoiding staying in the sun for extended periods of time D. not applying the cream directly on lesions

C Vitamin A makes the skin more susceptible to ultraviolet rays, thereby increasing the chance for sunburn.

A pregnant client is prescribed to have labor induced with oxytocin. The nurse is preparing to administer the medication. Which action is appropriate? A. Prepare a syringe with a bolus dose of medication. B. Give the initial dose as an intramuscular injection. C. Use a port closest to the client for the oxytocin infusion. D. Add the oxytocin to the prescribed Ringer's lactate main infusion.

C When administering oxytocin, the infusion should be "piggybacked" to a maintenance IV solution and add the piggyback to the main infusion at the port closest to the client. If the oxytocin needs to be discontinued quickly during the induction, and solution remains in the tubing to still infuse, and the main IV line can still be maintained. Oxytocin is not administered as an intravenous bolus nor initial intramuscular injection. Oxytocin is not diluted in the main intravenous fluid.

The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart sounds? A. low in the abdomen B. left lateral abdomen C. high in the abdomen D. right lateral abdomen

C With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral abdominal regions.

A client has just given birth to a healthy newborn, but the placenta has not yet been delivered. Suddenly there is a large gush of blood from the vagina. Abdominal palpation reveals the lack of a palpable fundus. Further assessment reveals diaphoresis and pallor. The client reports dizziness. Blood pressure is 80/50 mm Hg. Which response(s) is appropriate? Select all that apply. A. Begin an oxytocin infusion via a central venous access device. B. Decrease the intravenous fluid rate to 80 ml/hour. C. Administer supplemental oxygen via face mask. D. Assess vital signs frequently for changes. E. Assist with removing any pieces of the placenta if seen.

C, D Based on the client's assessment findings, the client is experiencing uterine inversion. In this situation, the nurse will immediately call for help if primary care providers are not already at the bedside. Oxytocin, if being used, will be discontinued because it makes the uterus more tense and difficult to replace. An IV fluid line will be inserted if one is not already present (use a large-gauge needle because blood will need to be replaced). If a line is already in place, the nurse will open it to achieve optimal flow of fluid to restore fluid volume. The nurse will administer oxygen by mask and assess vital signs. The nurse needs to be prepared to perform cardiopulmonary resuscitation (CPR) if the client's heart should fail from the sudden blood loss. Attempts to replace an inversion should never be done, because handling of the uterus could increase the bleeding. Also, the nurse should never attempt to remove the placenta if it is still attached, because this would create a larger surface area for bleeding.

The community nurse is caring for a family who has a child with a long-term illness. At which point in life should the nurse anticipate the parents having the least difficult time accepting the child's condition? A. on the child's first birthday B. the day the child starts kindergarten C. the day the child is toilet trained D. the day the child would have graduated college

D : A child's illness usually appears to be more acute at times when the child would normally reach developmental milestones. When the child does not reach these traditional milestones, it reminds parents about their child's illness in a particularly painful way. The first birthday, starting kindergarten, and being toilet trained are momentous occasions for families raising children. The family may or may not view attending college as a priority.

The parents of a 5-year-old boy who is very near death are at the bedside.The parents ask, "Can he hear what we are telling him?" Which response by the nurse would be most appropriate? A. "No, now that he is semicomatose, there is no way he is able to hear you." B. "No one really knows, so it is a good idea to make sure that you whisper quietly." C. "Yes, he is able to hear everything you say and understand it completely." D. "Yes, he can hear what you are telling him and may be able to understand most of it."

D A loss of consciousness occurs as children grow closer and closer to death. They may, however, remain perfectly alert until seconds before death. Because hearing is one of the last senses lost, the nurse may need to remind family members and other health care personnel that the child may not be able to respond but may be able to hear. Continue to explain procedures to unconscious children as if they were conscious because they undoubtedly do hear. Never make any comment in the child's presence that would not be made if the child were alert.

Which client's physical assessment finding of a school-age child should the nurse question as a potential indication of child abuse (child maltreatment)? A. a thin, tall appearance B. a scald burn on the chest C. a maculopapular rash on the buttocks D. linear abrasions on his ankles and wrists

D Abrasions or ecchymotic areas on the wrists or ankles may be present if the child was tied to a bed or against a wall. Being thin and tall is not an indication of abuse. A scald burn on the chest could have occurred while eating a meal at home. A rash on the buttocks is not an indication of physical abuse.

The nurse is caring for a 16-year-old adolescent who was arrested for driving while intoxicated. Which teaching method is most effective in changing the adolescent's behavior? A. scolding the client for such irresponsible behavior B. reviewing the long-term effects of alcohol on the liver C. teaching that alcohol eventually will lead to other drug abuse D. stressing that the driver's license can be lost if drinking continues

D Adolescents are very present-oriented, so a program such as losing the driver's license provides immediate results and will usually be carried out well. In contrast, a regimen oriented toward the future, with long-term goals such as effects of alcohol on the liver or leading to other drug use may not be as successful. Scolding is not a teaching method.

A nurse is preparing a presentation for a parent group at the local middleschool about the importance of immunizations. Which immunization is key to aid in reducing the risk of cervical cancer? A. measles, mumps and rubella (MMR) B. varicella C. meningococcus D. human papillomavirus (HPV)

D Although all immunizations are important, the human papillomavirus (HPV) is the virus associated with cervical cancer and immunization is recommended for or all people aged 9 through 45 years.

Which of the following statements probably would be most therapeutic to an adolescent seen for rape? A. "Try not to think any more about what happened." B. "Rape is a terrible crime. I'm sorry this happened." C. "Tell me about what happened to you." D. "Don't feel guilty; you did not provoke the attack."

D Discussing any event allows it to be "fenced" and brought down to a workable size. Adolescents do not provoke rape. They are the victims.

The nurse is caring for the couple in which the wife is considering tubal ligation because she is concerned about her children inheriting her husband's family's intellectual disability. Which would be a primary nursing intervention? A. Help the woman reject the idea of sterilization. B. Strengthen the couple's resolve to remain childless. C. Help the couple decide to have children. D. Increase the couple's knowledge about genetic inheritance.

D Education about genetic patterns allows people to make informed decisions.

The estrogen content in the contraceptive pill performs which action? A. decreases the permeability of cervical mucus B. increases the level of luteinizing hormone (LH) C. interferes with endometrial proliferation D. suppresses follicle-stimulating hormone (FSH)

D Estrogen has a direct effect on the pituitary gland suppressing FSH; progesterone increases permeability of cervical mucus and endometrial proliferation.

An adolescent female who has recently started menstruating asks for a highly reliable birth control method. Which method should the nurse discuss with the client? A. postcoital douching B. an intrauterine device (IUD) C. an ovulation suppressant D. vaginal foam for her and a condom for her partner

D For many adolescent couples, use of a dual method, such as a vaginally inserted spermicide by the girl and a condom by her partner, is a preferred method of birth control. Douching after sex is not a method of birth control. Intrauterine devices are rarely used for early adolescents because the uterus may still be small. Ovulation suppressants are not recommended until a female has been menstruating for at least 2 years.

During a physical assessment, a 15-year-old male expresses concern about being short in height. When responding to the client, the nurse would incorporate an understanding of which information about growth? A. Most male adolescents stop growing by age 17 years. B. Maximum height is typically achieved by age 14 years. C. The epiphyseal lines of long bones close when signs of puberty occur. D. The epiphyseal lines of long bones close at about 18 to 20 years of age inmales.

D Growth stops with closure of the epiphyseal lines of long bones, which occurs at about 18 to 20 years of age in males. Most adolescent males do not stop growing by age 17 years. Maximum height is not achieved by age 14 years. The epiphyseal lines of long bones do not close when signs of puberty occur.

Which description best explains the hysterosalpingogram procedure? A. insertion of an endoscope through the posterior fornix to visualize the reproductive organs B. instillation of carbon dioxide through the cervix into the uterus and fallopian tubes C. passage of an endoscope through a small abdominal incision to inspect the reproductive organs D. radiograph of the uterus and fallopian tubes following introduction of a radiopaque medium through the cervix

D Hysterosalpingogram is a procedure to document the patency of the fallopian tubes through the use of a radiopaque medium.

An adolescent is concerned that although he has pubic hair, he has no facial hair yet. He wishes facial hair would grow to cover acne lesions. The nurse would advise him that facial hair: A. usually grows before pubic hair. B. is rarely present before 20 years of age. C. is delayed in boys with acne. D. usually follows pubic hair growth.

D In the average adolescent, pubic hair develops at 13 to 15 years, facial hair at 15 to 16.

To be an effective nurse with a female child who is dying, it is first necessary to: A. explain the stages of grief to her parents. B. assess at which stage of grief the parents are. C. help the child understand the grieving process. D. identify your own reactions and feelings about death.

D It is difficult for a nurse to help children and parents deal with dying and grief until the nurse understands it personally for himself or herself.

The nurse notes that a chronically ill child has not been seeing the health care provider for several months, although monthly checkups and blood work are needed to help maintain the illness. What should the nurse suspect as a reason for the child missing appointments? A. The parents have been too busy to bring the child. B. The family does not have the money to pay for multiple visits. C. The child is afraid of having the blood drawn, so the parents do not bring him. D. The parents are having a difficult time grieving with the idea of the child's illness.

D Most parents of a chronically ill child adhere well to instructions andkeep health care appointments consistently. Sometimes, however, parents do not follow this pattern. This inability to adhere usually is related to their stage of adjustment to the illness. As long as denial, anger, bargaining, or depression is functioning, coming in for health care or evaluation is viewed as a major demand. Each visit is more of a reminder of the child's illness than a time of reassuring health assessment. This behavior does not indicate that the parents are too busy. There is not enough information to determine if the visits are cost-prohibitive for the family. There is not enough information to determine if the child is afraid of having blood tests performed.

The nurse instructs a client on cervical mucus changes that occur during ovulation. Which statement indicates that teaching has been effective? A. "During ovulation, the mucus is thick." B. "Ovulation makes the mucus more acidic." C. "The mucus is white because of more white blood cells." D. "When the mucus is thin and watery, then ovulation is occurring."

D On the day of ovulation, the cervical mucus becomes copious, thin, watery, and transparent. During ovulation, the mucus is not thick, not acidic, and not white.

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? A. Administer oxytocin in a 20 cc bolus of saline. B. Administer oxytocin in two divided intramuscular sites. C. Administer oxytocin diluted in the main intravenous fluid. D. Administer oxytocin diluted as a "piggyback" infusion.

D Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

How can pelvic inflammatory disease (PID) affect fertility? A. It causes anovulation because of interference with secretion of pituitary hormones. B. It causes changes in cervical mucus that make it less receptive to penetration by sperm. C. It causes sperm-agglutinating antibodies to be produced in the vagina. D. It interferes with the transport of ova because of tubal scarring.

D Pelvic inflammatory disease, or infection of the fallopian tubes, results in scarring and adhesions of the tubes, leading to poor transport of ova.

The nurse is caring for a preschool-age child who is aware of impending death. Based on the child's development, the nurse would incorporate an understanding of which concept into the child's plan of care? A. The child is likely to have frequent outbreaks of anger B. The child will need a lot of time to verbalize feelings C. The child will actively bargain for an another chance. D. The child has an underlying fear of being separated from parents

D Preschoolers fear separation. If able to grasp the concept of dying, this child's major worry is being alone and separated. These children may need someone to stay with them constantly to reassure them that they are loved and people are caring for them. Anger, verbalization of feelings, and bargaining are not behaviors typically associated with a preschool age-child who is facing death.

When reviewing normal menstruation with an early adolescent, the nurse would teachthe girl that during the second half of a typical menstrual cycle, the endometrium of the uterus becomes: A. thin and transparent because of progesterone stimulation. B. twisted and ragged because of follicle-stimulating hormone. C. thick and purple-hued because of estrogen stimulation. D. corkscrew-like because of progesterone stimulation.

D Progesterone is released following ovulation and thus is the dominating hormone of the second half of the menstrual cycle; its effect is to increase endometrium growth.

The nurse is teaching a client on the use of a diaphragm for contraception. Which client statement indicates that the instruction has not been effective? A. "I need to use my finger to remove the diaphragm." B. "I should remove the diaphragm 6 hours after intercourse." C. "I should stop using a diaphragm if I get an infection of my cervix." D. "I need to have the diaphragm checked if my weight changes by 30 lb."

D The client should be instructed to have the size of the diaphragm checked if weight changes by 15 lb. The client does need to use the finger to remove the diaphragm. The diaphragm should be removed 6 hours after intercourse. The diaphragm should not be used if the client is experiencing a cervical infection.

A woman visits the family planning clinic to request a prescription for birth control pills. Which factor would indicate that an ovulation suppressant would not be the best contraceptive method for her? A. She is 30 years old. B. She has irregular menstrual cycles. C. She has a history of allergy to foreign protein. D. She has a family history of thromboembolism.

D The estrogen content of birth control pills may lead to increased blood clotting, leading to an increased incidence of thromboembolism. Women who already are prone to this should not increase their risk further.

The nurse is planning an educational session on contraceptives for a group of adolescent high school students. What does the nurse need to do when planning this session? A. Argue that encouraging abstinence is unrealistic during the teenage years. B. Discuss that the application of a condom should occur after penile-vulvar contact. C. Explain that oral contraceptive pills (OCPs) are best for adolescents. D. Teaching about contraceptive options while avoiding indirect encouragement ofsexual activity.

D The nurse can help the nation achieve the 2020 National Health Goals by teaching adolescents about contraceptive options while being cautious to avoid indirectly encouraging sexual activity among teens. A 2020 National Health Goal is to increase the number of adolescents being instructed on abstinence. A condom should be applied before penile-vulvar contact. Oral contraceptive pills are not the contraceptive of choice for adolescents.

When using the contraceptive patch, a client should understand that it: A. should be applied to the breasts, hips, or back. B. should be covered when swimming in a pool because of chlorine's effect on the adhesive. C. is immediately effective after application. D. should be applied to the abdomen, buttocks, or back.

D The patch should be applied only to the buttocks, back, abdomen, or torso (never the breasts). The patch is safe for wearing during swimming and bathing. The patch requires application for 1 week before becoming effective.

The nurse is caring for a chronically ill adolescent client. When developing the plan of care for this client, which area would the nurse focus on to maintain stimulation and support the client's sense of identity while hospitalized? A. Plan interventions to fall around scheduled rest periods. B. Teach the client about food choices appropriate to the prescribed diet. C. Instruct on the name and indications for use of all medications. D. Encourage keeping in contact with friends through social media.

D To encourage stimulation while supporting the adolescent client's sense of identity while hospitalized, the nurse should encourage the client to communicate with friends through social media. Planning activities around rest periods does not promote stimulation. Explaining food choices does not promote stimulation. Learning about medications does not promote stimulation.

The nurse is preparing to discuss the most frequent causes of death in adolescents with a group of high school students. On which area should the nurse focus during this discussion? A. water safety B. home safety C. firearm safety D. motor vehicle safety

D Unintentional injuries, most commonly those involving motor vehicles, are the leading cause of death among adolescents. This is the area in which the nurse should focus during the discussion with the high school students. Water, home, and firearm safety are not identified as leading causes of death in adolescents.