Practice Questions 3:
Which is the appropriate intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration? - elevating the legs - repositioning the client from side to side - increasing the rate of intravenous infusion - administering oxygen by way of face mask
- reposting the client from side to side rationale: A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Elevating the legs and increasing the rate of intravenous fluid administration are interventions for placental perfusion problems and do not affect cord compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation.
Which statement accurately describes the current advice regarding breast self-examination (BSE)? - BSEs clearly decrease mortality - BSEs prevent unnecessary testing - BSEs should be done immediately before menstruation - BSE should be taught to all women
- BSE should be taught to all women rationale: It is true that the American Cancer Society and breastcancer.org continue to recommend self-examinations. BSEs do not clearly decrease mortality. Rather than save women from unnecessary testing, they tend to result in unnecessary procedures, including biopsies. It's best to do self-examinations when breasts are not tender or swollen as they often are right before or after menstruation.
Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. Which action would the nurse take in response to these findings? - stop the infusion of magnesium sulfate and notify the primary health care provider - administer calcium gluconate, because it is an antidote to magnesium sulfate - continue the magnesium sulfate infusion, because the blood pressure is still high - check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary
- Stop the infusion of magnesium sulfate and notify the primary health care provider rationale: Near-toxic levels of magnesium sulfate are suggested by the disappearance of the knee-jerk reflex and by depressed respirations (fewer than 12 breaths/min). This is a life-threatening situation, and the infusion must be stopped and the primary health care provider notified immediately. Calcium gluconate may be given as an antidote, but the infusion of magnesium sulfate must be stopped first. Magnesium sulfate is not an antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention.
Which assessment finding indicates that a client at 40 weeks' gestation is experiencing true labor? - cervical dilation - membrane rupture - decreased fetal heart rate - intensification of contractions
- cervical dilation rationale: True labor is marked by cervical dilation, effacement, or both. It is not uncommon for membranes to rupture before true labor begins. A change in the fetal heart rate does not indicate true labor; the rate may be slowing because the fetus is resting or fetal compromise is occurring. The client's perception of the intensity of contractions is not an indication of true labor. Because of admission to the hospital and loss of diversionary activities, the client may perceive the contractions as becoming more intense.
A pregnant client in the third trimester tells the nurse in the prenatal clinic that she is experiencing heartburn after every meal. Which explanation would the nurse provide regarding the cause of the heartburn? - the esophageal sphincter relaxes and allows acid to be regurgitated - in pregnancy, gastric motility increases, causing a burning sensation - in pregnancy, gastric pH increases, causing acid to enter the esophagus - in pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine
- the esophageal sphincter relaxes and allows acid to be regurgitated rationale: Relaxation of the esophageal sphincter, resulting in regurgitation of acid, causes heartburn (pyrosis) during the second half of pregnancy. Delayed emptying of stomach contents because of decreased gastric motility and displacement of the stomach because of uterine enlargement contribute to the problem. When gastric pH increases, gastric juices become more alkaline, leaving little or no acid to be regurgitated into the esophagus. The pyloric sphincter does not relax, and acid does not pass into the small intestine.
Which complication is prevented by coaching a client in the second stage of labor to take a breath at least every 6 seconds while pushing with each contraction? - fetal hypoxia - perennial lacerations - carpopedal spasms - maternal hypertension
- fetal hypoxia rationale: Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.
Which is the optimal area for the nurse to assess adequate tissue oxygenation in an African-American neonate? - heels and buttocks - upper tips of the ears - nail beds on the hands and feet - mucous membranes of the mouth
- mucous membranes of the mouth rationale: Lack of skin pigmentation on the surfaces of the mucous membranes makes this the best area in which to assess this neonate's tissue oxygenation. Heels and buttocks are usually highly pigmented areas, and the buttocks often have Mongolian spots. The tips of the ears will indicate skin color later in life. Because most neonates' hands and feet exhibit acrocyanosis, the nail beds may be cyanotic as well.
Which action would the nurse take when a 15-beat-per-minute acceleration of the fetal heart rate above the baseline occurs during a contraction? - call the practitioner to prepare for imminent birth - turn the mother on her left side to increase venous return - record the fetal response to contractions and continue to monitor the heart rate - document the fetal heart rate abnormality and monitor the fetal heart rate continuously
- record the fetal response to contractions and continue to monitor the heart rate rationale: Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. The fetal response is recorded and monitoring continues unchanged. This increase in the fetal heart rate does not require intervention by the practitioner at this time. Turning the mother on her left side to increase venous return is done when a fetal heart rate deceleration occurs. This acceleration is not a fetal heart rate abnormality and does not require a specific frequency of monitoring.
A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions, the client says, "That sounds gross. I don't think I can do it." Which conclusion would the nurse make from this statement? - the client is unduly fastidious - the client feels that having a baby is not that important - the client may be uncomfortable with performing manual examination of genitals - the client is afraid that she is the cause of the infertility
- the client may be uncomfortable with performing manual examination of genitals rationale: Some women find it emotionally stressful to handle their genitals and discharges. The nurse would need to question the client further to determine if this is the case. The nurse does not have data to support whether the client is unduly fastidious. The nurse would not pass judgment on whether or not the client desires having a baby. Although many women in this situation feel that they are the cause of infertility, this has no bearing on either the nurse's instruction or the client's response.
The nurse is assessing a pregnant 16-year-old client. Which factors associated with adolescent pregnancy would the nurse consider when developing a plan of care for this client? Select all that apply. One, some, or all responses may be correct. - higher rate of postpartum depression - inappropriate dietary choices - higher rate of anemia - incomplete bone mass - underdeveloped secondary sex characteristics
- higher rate of postpartum depression - inappropriate dietary choices - higher rate of anemia - incomplete bone mass rationale: Adolescents have higher rates of postpartum depression than older women. An important aspect of nursing care for pregnant adolescents is to engage with them during the pregnancy and provide a supportive, welcoming environment and to develop a network of community resources supportive of pregnant and parenting teens to address their psychosocial issues. Adolescents may have inadequate diets and eat more fast foods. The diet is generally high in fats and carbohydrates and deficient in protein, calcium, fruits, and vegetables. Anemia is more common in teens and intensive nutrition evaluation and counseling is indicated. Peak bone mass is reached in the late teens or early 20s. When a teen is pregnant, higher levels of calcium are required to both provide support for the pregnancy and to support the teen's own bone health. Secondary sex characteristics appear early and are complete by the end of puberty; if the adolescent is pregnant, she has completed puberty.
A client with a 35-day menstrual cycle is trying to become pregnant. The nurse would counsel the client and her partner that the optimal timing of intercourse to achieve pregnancy would be on which day? - on the 12th day of the cycle - on the 14th day of the cycle - on the 21st day of the cycle - on the 25th day of the cycle
- on the 21st day of the cycle rationale: Ovulation usually occurs 14 days before menses; in a 35-day cycle, ovulation may occur as late as the 21st day. Day 12 of the cycle is the proliferative phase; ovulation has not yet occurred. If the woman has a 28-day cycle, ovulation is expected on the 14th day of the cycle. By the 25th day of the cycle, the ovum in this woman has passed out of the fallopian tube and can no longer be fertilized.
The nurse is teaching a group of new mothers regarding the benefits of breast-feeding. Which factor would have a significant effect on the success of breast-feeding? - age of the woman at the time of delivery - distribution of erectile tissue in the nipples - amount of milk products consumed during pregnancy - viewpoint of the woman's family toward breast-feeding
- viewpoint of the woman's family toward breast-feeding rationale: If the woman perceives that significant others in her life hold a negative view of breast-feeding, she may be tense, and the let-down reflex may not occur; a positive attitude on the part of significant others toward breast-feeding promotes relaxation and the let-down reflex. If the significant persons in her life do not support breast-feeding, she will have little encouragement to breast-feed and to get through the challenges that breast-feeding may present. The age of the woman at the time of the birth and distribution of erectile tissue in the nipples have no influence on lactation. Intake of milk or milk products during pregnancy has little influence on lactation.