Practice Questions 1:
Which information concerning a safe feeding technique would the nurse provide to a mother whose newborn infant son has a cleft lip and palate? - "Because he tires easily, it's best to have him lying in bed while he is being fed." - "Hold him in a horizontal position and feed him slowly to help prevent aspiration." - "Give him frequent rest periods and frequent burpings during feedings so he can get rid of swallowed air." - "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion."
- "Give him frequent rest periods and frequent burpings during feedings so he can get rid of swallowed air." rationale: Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.
A woman who is 34 weeks' pregnant is hospitalized for pyelonephritis. Which assessments would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. - homan sign - urine output - temperature - dietary sodium - blood pressure - uterine contractions
- urine output - temperature - blood pressure - uterine contractions rationale: Urine output is significant, because the urinary system is involved in the infection. Symptoms of urinary tract infections (UTIs) usually include temperature elevations. A common complication of a UTI/pyelonephritis in pregnancy is preterm labor, so contractions should be monitored. Blood pressure should be monitored to ensure that septicemia, if it occurs, will be identified early. The Homan sign is thought to be an indication of deep vein thrombosis and is not associated with UTI. Dietary sodium is not an issue with a UTI.
Which criterion would the nurse use when assessing the gestational age of a preterm infant? - reflex stability - simian creases - breast bud size - fingernail length
- breast bud size rationale: The size of the breast buds is an indication of gestational age. Small, underdeveloped nipples reflect prematurity. Reflex stability is not a reliable indicator of gestational age; also, reflexes may be impaired in full-term infants. The simian crease is a single palm crease that is a clinical manifestation of Down syndrome, not of prematurity. Although the nails may be longer in a postterm infant, nail length is not a reliable indicator in a preterm infant.
Which prescriptions would the nurse expect to receive for a client with mild preeclampsia and increasing blood pressure? Select all that apply. One, some, or all responses may be correct. - daily weight - side-lying bed rest - 2 g/day sodium diet - monitor deep tendon reflexes - glucose tolerance test
- daily weight - side-lying bed rest - monitor deep tendon reflexes rationale: Rapid weight gain is a sign of increasing edema. One liter of fluid is equal to 2.2 lb. Maintaining bed rest promotes fluid shift from the interstitial spaces to the intravascular space, which enhances blood flow to the kidneys and uterus; the side-lying position promotes placental perfusion. A 2 g/day sodium diet will deplete the circulating blood volume, limiting blood flow to the placenta. A moderate sodium intake (6 g or less) is permitted as long as the client is alert and has no nausea or indication of an impending seizure. Deep tendon reflexes should be monitored. Reflexes of +2 are indicative of mild preeclampsia; +4 indicates severe preeclampsia. There are no data indicating that a glucose tolerance test is needed.
After the vaginal birth of an infant weighing 8 lb, 13 oz (3997 g) an ice pack is applied to a client's perineum to ease the swelling and pain. Subsequently the client complains, "My vagina feels so full and heavy and the pain in it and in my rectum is excruciating." Which problem would the nurse suspect is the cause of the pain? - full bladder - vaginal hematoma - infected episiotomy - enlarged hemorrhoids
- vaginal hematoma rationale: A vaginal hematoma caused by fetal head pressure during the birthing process can result in severe pain. Bladder distention causes abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should not be excruciating; it is too early for an infection to have developed. Although hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel full and heavy.
When teaching a client about using a diaphragm as a form of contraception, which instructions would the nurse provide about the diaphragm? - it may or may not be used with a spermicidal lubricant - it should remain in place for at least 6 hours after intercourse - it must be removed and replaced if intercourse occurs again within 2 hours - it often appears puckered, but this will not interfere with its effectiveness
- it should remain in place for at least 6 hours after intercourse rationale: The diaphragm should remain in place for at least 6 hours after intercourse because the spermicidal jelly or cream requires this amount of time to be effective. The diaphragm must always be used with a spermicide to be effective. If another act of intercourse occurs after 2 hours, the diaphragm should be left in place and additional spermicidal gel should be inserted into the vagina. The diaphragm should then be left in place for 6 to 8 hours after the last act of intercourse. Puckering, especially near the rim, may indicate thin spots that could rupture during intercourse; the diaphragm should be replaced if puckering is found.
A sonogram performed on a client in the third trimester reveals a low-lying placenta. Which would the nurse teach the client that she is at risk for? - sharp abdominal pain - painless vaginal bleeding - increased lower back pain - early rupture of membranes
- painless vaginal bleeding rationale: This client's placenta is implanted near the internal cervical os; in the latter part of pregnancy, as the process of effacement occurs, placental separation from the uterus causes painless bleeding. Sharp abdominal pain occurs with abruptio placentae, the premature separation of a normally situated placenta. Increased lower back pain is not specific to a low-lying placenta. Early rupture of membranes is not specific to a low-lying placenta.
Which condition is suspected when immediately after a client's membranes rupture, the fetal heart rate monitor shows variable decelerations of more than 90 seconds followed by bradycardia? - fetal acidosis - prolapsed cord - head compression - uteroplacental insufficiency
- prolapsed cord rationale: This variable pattern with bradycardia is an ominous sign; it is indicative of a prolapsed cord, or cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidosis, not fetal heart rate changes, occurs with uteroplacental insufficiency. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia, not variable decelerations followed by bradycardia, are associated with uteroplacental insufficiency.
Which position is the fetus in when Leopold maneuvers disclose a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus? - left occiput posterior (LOP) - right sacral anterior (RSA) - right occiput anterior (ROA) - left occipital anterior (LOA)
- right occiput anterior (ROA) rationale: The fetus is in an ROA position; the prominence over the symphysis suggests a vertex presentation, and the fetal occiput and back are in the right anterior quadrant. LOP is ruled out because the occiput is not located in the left posterior quadrant; the occiput and back are on the mother's right side. RSA is ruled out because the fetus is in a vertex, not a breech, presentation. LOA is ruled out by the presence of irregular lumps on the left side, suggesting that the fetus's back is in the mother's right quadrant.
Which method would the nurse use to best elicit the Moro reflex in a full-term newborn? - touching the infant's cheek - striking the surface of the infant's crib suddenly - allowing the infant's feet to touch the surface to the crib - stroking the sole of the foot along the outer edge from the heel to the toe
- striking the surface of the infant's crib suddenly rationale: Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.
A client is crying after undergoing dilation and curettage after an early miscarriage (spontaneous abortion). Which response would the nurse give? - this must be a very difficult experience for you to deal with - you'll have other children to take the place of the child you lost - of course you're sad now, but at least you know you can get pregnant - I know how you feel, but when a woman miscarries, it's usually for the best
- this must be a very difficult experience for you to deal with rationale: Saying that this must be a difficult experience acknowledges the validity of the client's grief and provides the client an opportunity to talk if she wishes. Other children cannot and should not be substituted for a lost fetus. Getting pregnant is not the issue; this statement belittles the lost fetus. The nurse cannot know how the client feels. Stating that a miscarriage is for the best is patronizing and diminishes the significance of the lost fetus.
The nurse explains to a client that she will need additional calcium during pregnancy and that the ideal source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." Which is an appropriate reply? - your practitioner can prescribe calcium supplements - just make sure that the rest of your diet is nutritionally sound - eliminating milk from your diet may cause your teeth to loosen - drinking milk is so important for your baby to develop strong bones
- your practitioner can prescribe calcium supplements rationale: Calcium is essential to a pregnant woman's diet for the development of the fetal skeleton; it must be supplemented if the client dislikes or is allergic to milk and milk products. A nutritionally sound diet without dairy products does not meet the needs of the pregnant woman or her fetus. Dental care and oral hygiene will be more beneficial for maintaining healthy teeth than adding more calcium to the diet will. If milk makes the client ill, the statement "Drinking milk is so important for your baby to develop strong bones" is ineffective advice, and the dietary regimen probably will not be followed.