QUIZZES
After teaching a woman who has had an evacuation for a hydatidiform mole (molar pregnancy) about her condition, which of the following statements indicates that the nurse's teaching was successful? A) "I will be sure to avoid getting pregnant for at least 1 year." B) "My intake of iron will have to be closely monitored for 6 months." C) "My blood pressure will continue to be increased for about 6 more months." D) "I won't use my birth control pills for at least a year or two."
A) "I will be sure to avoid getting pregnant for at least 1 year."
A nurse is teaching a pregnant couple about childbirth education. The nurse determines that the teaching was successful when the couple makes which statement? A) "We'll know what to do to actively take part in our child's birth." B) "We'll have the knowledge to ensure a pain-free childbirth." C) "We won't be anxious, so the birth will be uncomplicated." D) "We will be in total control of the birth process."
A) "We'll know what to do to actively take part in our child's birth."
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following? A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled
A) A good time to initiate breast-feeding Rationale: The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus
A) Cannot be palpated
An adolescent is diagnosed with gonorrhea. When developing the plan of care for this adolescent, the nurse would expect that she would also receive treatment for which of the following? A) Chlamydia B) Syphilis C) Genital herpes D) Trichomoniasis
A) Chlamydia
After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly B) Put a hat on the newborn's head C) Check the newborn's temperature D) Wrap the newborn in a blanket
A) Dry the newborn thoroughly
A multipara client develops thrombophlebitis after delivery. Which assessment finding would lead the nurse to intervene immediately? A) Dyspnea, diaphoresis, hypotension, and chest pain B) Dyspnea, bradycardia, hypertension, and confusion C) Weakness, anorexia, change in level of consciousness, and coma D) Pallor, tachycardia, seizures, and jaundice
A) Dyspnea, diaphoresis, hypotension, and chest pain
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? A) Elevated liver enzymes B) DIC C) Hyperglycemia D) Elevated platelet count
A) Elevated liver enzymes
A nurse is assessing a pregnant woman on a routine checkup. When assessing the woman's gastrointestinal tract, which of the following would the nurse expect to find? Select all that apply. A) Hyperemic gums B) Increased peristalsis C) Complaints of bloating D) Heartburn E) Nausea
A) Hyperemic gums C) Complaints of bloating D) Heartburn E) Nausea
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which of the following? A) Linea nigra B) Striae gravidarum C) Melasma D) Vascular spiders
A) Linea nigra
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of labor B) Probable hypoglycemia C) Physiological immunity D) Inadequate oxygenation
A) Normal progression of labor
The public health nurse is teaching young adolescents in a sexual health class the proper use of a condom. Which statement by the students indicate teaching was successful? Select all that apply. A) Only use latex condoms B) Baby oil is an acceptable lubrication C) Place the condom on an erect penis D) Ensure a tight fit of the condom E) Store condoms in a cool, dry place
A) Only use latex condoms C) Place the condom on an erect penis E) Store condoms in a cool, dry place
In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse integrates which of the following in to the explanation? A) Pressure of the gravid uterus on the vena cava B) A 50% increase in blood volume C) Physiologic anemia due to hemoglobin decrease D) Pressure of the presenting fetal part on the diaphragm
A) Pressure of the gravid uterus on the vena cava
The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. Which findings would the nurse most likely assess? Select all that apply. A) Significant difficulty breathing B) Hypertension C) Tachycardia D) Pulmonary edema E) Bleeding with bruising
A) Significant difficulty breathing C) Tachycardia D) Pulmonary edema E) Bleeding with bruising Rationale: The clinical appearance is varied, but most women report difficulty breathing. Other symptoms include hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, pulmonary edema, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest.
A female sex trade worker has been diagnosed with secondary syphilis. Which findings would most likely correlate with this diagnosis? A) Sore throat and flu-like symptoms B) Pain-free crusty genital lesions C) Yellow vaginal discharged D) Painful dysurea
A) Sore throat and flu-like symptoms
Which of the following would indicate to the nurse that the placenta is separating? A) Uterus becomes globular B) Fetal head is at vaginal opening C) Umbilical cord shortens D) Mucous plug is expelled
A) Uterus becomes globular Rationale: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.
The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply. A) Washing hands before and after perineal care B) Directing peribottle to flow from back to front C) Taking the prescribed antibiotic until it is finished D) Handling perineal pads by the edges E) Checking temperature once a week
A) Washing hands before and after perineal care C) Taking the prescribed antibiotic until it is finished D) Handling perineal pads by the edges Rationale: Teaching should address taking the prescribed antibiotic until finished to ensure complete eradication of the infection; checking temperature daily and notifying the practitioner if it is above 100.4° F; washing hands thoroughly before and after eating, using the bathroom, touching the perineal area or providing newborn care; handling perineal pads by the edges and avoiding touching the inner aspect of the pad that is against the body; and directing peribottle so that it flows from front to back.
A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A) "I'm feeling contractions mostly in my back." B) "My contractions are about 6 minutes apart and regular." C) "The contractions slow down when I walk around." D) "If I try to talk to my partner during a contraction, I can't."
Ans C: "The contractions slow down when I walk around." Rationale: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.
During a woman's physical examination, the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as: A) Hagar's sign B) Goodall's sign. C) Chadwick's sign D) Ortolan's sign
Ans: A Rationale: At approximately 6 weeks of gestation, softening of the lower uterine segment occur; this is called Hagar's sign
After teaching a group of adolescents about HIV, the nurse asks them to identify the major means by which adolescents are exposed to the virus. The nurse determines that the teaching was successful when the group identifies which of the following? A) Sexual intercourse B) Sharing needles for IV drug use C) Perinatal transmission D) Blood transfusion
Ans: A Rationale: Nurses can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing to adolescents. Most sexually active youth do not feel that they are at risk of contracting HIV and have never been tested. Obtaining a sexual history and creating an atmosphere that promotes nonjudgmental risk counseling is a key component of the adolescent visit. In light of increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the CDC recommends universal and routine HIV testing for all clients seen in health care settings who are 13 to 64 years of age. Sharing contaminated needles, perinatal transmission, and blood transfusions are not associated with adolescents and HIV.
Which findings would the nurse expect to find in a client with bacterial vaginosis? A) Vaginal pH of 3 B) Fish-like odor of discharge C) Yellowish-green discharge D) Cervical bleeding on contact
Ans: B Rationale: Manifestations of bacterial vaginosis include a thin, white homogenous vaginal discharge with a characteristic stale fish odor, vaginal pH greater than 4.5, and clue cells on wet-mount examination. A yellowish-green discharge with cervical bleeding on contact would be characteristic of trichomoniasis.
When obtaining the health history from a client, which factor would lead the nurse to suspect that the client has an increased risk for sexually transmitted infections (STIs)? A) Hive-like rash for the past 2 days B) Five different sexual partners C) Weight gain of 5 lbs in 1 year D) Clear vaginal discharge
Ans: B Rationale: The number of sexual partners is a risk factor for the development of STIs. A rash could be related to numerous underlying conditions. A weight gain of 5 lbs in one year is not a factor increasing one's risk for STIs. A change in the color of vaginal discharge such as yellow, milky, or curd-like, not clear, would suggest an STI.
Assessment of a female client reveals a thick, white vaginal discharge. She also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has: A) Trichomoniasis B) Bacterial vaginosis C) Candidiasis D) Genital herpes simplex
Ans: C Rationale: A thick, white vaginal discharge accompanied by intense itching and dyspareunia suggest vulvovaginal candidiasis. Trichomoniasis is characterized by a heavy yellow, green, or gray frothy or bubbly discharge. Bacterial vaginosis is manifested by a thin, white homogenous vaginal discharge with a characteristic stale fish-like odor. Genital herpes simplex involves genital ulcers.
The nurse encourages a female client with human papillomavirus (HPV) to receive continued follow-up care because she is at risk for: A) Infertility B) Dyspareunia C) Cervical cancer D) Dysmenorrhea
Ans: C Rationale: Clinical studies have confirmed that HPV is the cause of essentially all cases of cervical cancer. Therefore, the client needs continued follow-up for Pap smears. HPV is not associated with an increased risk for infertility, dyspareunia, or dysmenorrhea.
A client with genital herpes simplex infection asks the nurse, "Will I ever be cured of this infection?" Which response by the nurse would be most appropriate? A) "There is a new vaccine available that prevents the infection from returning." B) "All you need is a dose of penicillin and the infection will be gone." C) "There is no cure, but drug therapy helps to reduce symptoms and recurrences." D) "Once you have the infection, you develop an immunity to it."
Ans: C Rationale: Genital herpes is a lifelong viral infection. No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes. A vaccine is available for HPV infection but not genital herpes. Penicillin is used to treat syphilis. No immunity develops after a genital herpes infection.
A woman gives birth to a healthy newborn. As part of the newborn's care, the nurse instills erythromycin ophthalmic ointment as a preventive measure related to which STI? A) Genital herpes B) Hepatitis B C) Syphilis D) Gonorrhea
Ans:D Rationale: To prevent gonococcal ophthalmia neonatorum, erythromycin or tetracycline ophthalmic ointment is instilled into the eyes of all newborns. This action is required by law in most states. The ointment is not used to prevent conditions related to genital herpes, hepatitis B, or syphilis.
After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A) "Holding a pillow against my incision will help me when I cough." B) "I'm going to have to wait a few days before I can start breast-feeding." C) "I guess the nurses will be getting me up and out of bed rather quickly." D) "I'll probably have a tube in my bladder for about 24 hours or so."
B) "I'm going to have to wait a few days before I can start breast-feeding." Rationale: Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.
A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy and that is what causes this type of stool." B) "This is meconium stool and is normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual, and I need to report this to your pediatrician."
B) "This is meconium stool and is normal for a newborn."
The nurse is teaching a pregnant woman about recommended weight gain. The woman has a prepregnancy body mass index of 26. The nurse determines that the teaching was successful when the woman states that she should gain no more than which amount during pregnancy? A) 35 to 40 pounds B) 25 to 35 pounds C) 28 to 40 pounds D) 15 to 25 pounds
B) 25 to 35 pounds
A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of abruptio placenta during delivery. Which finding would help to support the nurse's suspicion? A) Inversion of the uterus B) Appearance of petechiae C) Board like abdomen D) Severe uterine pain
B) Appearance of petechiae
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus, expecting it to be at which location? A) Two fingerbreadths above the umbilicus B) At the level of the umbilicus C) Two fingerbreadths below the umbilicus D) Four fingerbreadths below the umbilicus
B) At the level of the umbilicus
The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation
B) Conduction
A nurse is conducting a refresher in-service program for a group of neonatal nurses. After teaching the group about hepatic system adaptations after birth, the nurse determines that the teaching was successful when the group identifies which process as reflective of the change of bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia
B) Conjugation
When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A) Extent of opening to its widest diameter B) Degree of thinning C) Passage of the mucous plug D) Fetal presenting part
B) Degree of thinning Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show is a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
A nurse is making a home visit to a postpartum client. Which finding would most likely lead the nurse to suspect that a woman is experiencing postpartum psychosis? A) Insomnia B) Delirium C) Feelings of guilt D) Sadness
B) Delirium
A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A) Respiratory rate of 16 breaths per minute B) Diminished deep tendon reflexes C) Urine output of 45mL/hr D) Alert level of consciousness
B) Diminished deep tendon reflexes Rationale: Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.
The nurse would be alert for possible placental abruption during labor when assessment reveals which finding? A) Macrosomia B) Gestational hypertension C) Gestational diabetes D) Low parity
B) Gestational hypertension Rationale: Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.
A nurse is conducting an in-service presentation to a group of prenatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that teaching was successful when the group identifies which infection as being responsible for opthalmia neonatorum? A) Syphilis B) Gonorrhea C) Chlamydia D) HPV
B) Gonorrhea
A pregnant woman tests positive for HBV. What would the nurse expect to administer? A) HBV vaccine B) HBV immune globulin C) Acylcovir D) Valacyclovir
B) HBV immune globulin
A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A) Prevents uterine muscle fatigue. B) Helps support the lower uterine segment. C) Determines that the procedure is effective. D) Aids in expressing accumulated clots.
B) Helps support the lower uterine segment.
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? A) Bladder distention B) Hematoma C) Uterine atony D) Laceration
B) Hematoma
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority? A) Jaundice B) Hemorrhage C) Infection D.) Edema
B) Hemorrhage
A client's last menstrual period was April 11. Using Nagele's rule, her expected date of birth (EDB) would be: A) January 4 B) January 18 C) January 25 D) February 24
B) January 18
A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which of the following? A) Excess folic acid, which could increase the risk for neural tube defects B) Mercury, which could harm the developing fetus if eaten in large amounts C) Lactose, which leads to abdominal discomfort, gas, and diarrhea D) Low-quality protein that does not meet the woman's requirements
B) Mercury, which could harm the developing fetus if eaten in large amounts
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following? A) Increased energy level with alternating strong and weak contractions B) Moderately strong contractions every 4 minutes, lasting about 1 minute C) Contractions noted in the front of abdomen that stop when she walks D) Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds
B) Moderately strong contractions every 4 minutes, lasting about 1 minute Rationale: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.
A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which of the following would the nurse be observing? A) Mother placing the newborn next to bare breast. B) Mother making eye-to-eye contact with the newborn C) Mother gently stroking the newborn's face D) Mother holding the newborn upright at the shoulder
B) Mother making eye-to-eye contact with the newborn
Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors
B) Motor maturity
A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? A) Massage the fundus B) Notify the health care provider C) Apply warm soaks to the area D) Encourage the client to void
B) Notify the health care provider
When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate? A) One who has undergone a previous myomectomy B) One who had a previous c-section via a low transverse incision C) One who has a history of contracted pelvis D) One who has a vertical incision from a previous c-section
B) One who had a previous c-section via a low transverse incision Rationale: VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.
The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which of the following would the nurse identify as the priority intervention? A) Position changes B) Pain relief measures C) Immediate cesarean birth D) Oxytocin administration
B) Pain relief measures Rationale: Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as which of the following? A) Quickening B) Pica C) Ballottement D) Linea nigra
B) Pica
A nurse is reviewing the medical record of a pregnant woman and notes that she is gravid II. The nurse interprets this to indicate the number of: A) Deliveries B) Pregnancies C) Spontaneous abortions D) Pre-term births
B) Pregnancies
Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy? A) Use or oral contraceptive for 5 years B) Recurrent pelvic infections C) Heavy, irregular menses D) Ovarian cyst 2 years ago
B) Recurrent pelvic infections
A pregnant woman comes to the clinic and tells the nurse that she has been having a whitish vaginal discharge. The nurse suspects vulvovaginal candidiasis, based on which assessment finding? A) Fever B) Vaginal itching C) Urinary frequency D) Incontinence
B) Vaginal itching
After teaching a pregnant woman with iron deficiency anemia about her prescribed iron supplement, which statement indicates successful teaching? A) "I should take my iron with milk." B) "I should avoid drinking orange juice." C) "I need to eat foods high in fiber." D) "I'll call the doctor if my stool is black and tarry."
C) "I need to eat foods high in fiber." Rationale :Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C-containing fluids such as orange juice are encouraged because they promote absorption.Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her doctor.
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? A) "It's strange, one minute I'm happy, the next I'm sad" B) "I keep hearing voices telling me to take my baby to the river." C) "I'm feeling so guilty and worthless lately." D) "I just feel so overwhelmed and tired."
C) "I'm feeling so guilty and worthless lately." Rationale: Indicators for postpartum depression include feelings related to restlessness, worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and loss of libido. Thus, the statement by the mother about feeling guilty and worthless suggest postpartum depression. The statements about being overwhelmed and fatigued and changing moods suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis.
A woman in her second trimester comes for a follow-up visit and says to the nurse, "I feel like I'm on an emotional roller-coaster." Which response by the nurse would be most appropriate? A) "How often has this been happening to you?" B) "Maybe you need some medication to level things out." C) "Mood swings are completely normal during pregnancy." D) "Have you been experiencing any thoughts of harming yourself?"
C) "Mood swings are completely normal during pregnancy."
A pregnant woman in the 36th week of gestation complains that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention would be most appropriate for the nurse to suggest? A) "Limit your intake of fluids." B) "Eliminate salt from your diet." C) "Try elevating your legs when you sit." D) "Wear Spandex-type full-length pants."
C) "Try elevating your legs when you sit."
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A) "I need to call my doctor if my temperature goes above 100.4° F (38° C)." B) "If I have chills or my discharge has a strange odor, I'll call my doctor." C) "When I put on a new pad, I'll start at the back and go forward." D) "I'll point the spray of the peri-bottle so it the water flows front to back."
C) "When I put on a new pad, I'll start at the back and go forward." Rationale: The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-to-back motion. Notifying the health care provider of a temperature above 100.4° F, aiming the peribottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching.
A nurse measures a pregnant woman's fundal height and finds it to be 28 cm. The nurse interprets this to indicate which of the following? A) 14 weeks' gestation B) 20 weeks' gestation C) 28 weeks' gestation D) 36 weeks' gestation
C) 28 weeks' gestation
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as: A) 3 2 1 0 3 B) 3 1 2 2 3 C) 4 1 1 1 3 D) 4 2 1 3 1
C) 4 1 1 1 3
A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? A) Offer warm blankets B) Encourage woman to void C) Apply an ice pack to the site D) Offer a warm sitz bath
C) Apply an ice pack to the site Rationale: An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.
When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) Deep red, fleshy-smelling lochia B) Voiding of 350 cc C) Blood pressure of 90/50mmHg D) Profuse sweating
C) Blood pressure of 90/50mmHg
A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which of the following in the newborn? A) Asphyxia B) Clavicular fracture C) Cephalhematoma D) Central nervous system injury
C) Cephalhematoma
On a follow up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? A) Feelings of anxiety B) Sadness C) Delusional beliefs D) Insomnia
C) Delusional beliefs
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? A) Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D) Bromocriptine (Parlodel)
C) Docusate (Colace)
A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? A) Compression stockings B) Warm compresses C) Early ambulation D) Prophylactic heparin administration
C) Early ambulation
A pregnant woman has a rubella titer drawn on her first prenatal visit. The nurse explains that this test measures which of the following? A) Platelet level B) Rh status C) Immunity to German measles D) Red blood cell count
C) Immunity to German measles
A nurse is assisting a client in active labor whose diabetes has been poorly controlled. Which assessment of the neonate should be prioritize after its birth? A) Hyperglycemia B) Low birthweight C) Macrosomia D) Hypobilirubinemia
C) Macrosomia
A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? A) Nonpalpable fundus B) Fever C) Moderate lochia serosa D) Bruising on arms and legs
C) Moderate lochia serosa
A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A) Sedatives B) Tocolytics C) Oxytocins D) Corticosteroids
C) Oxytocins Rationale: For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.
A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? A) Calf pain with dorsiflexion of the foot B) Leg pain on ambulation with mild ankle edema C) Sharp stabbing chest pain with shortness of breath D) Perineal pain with swelling along the episiotomy
C) Sharp stabbing chest pain with shortness of breath
A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A) Lochia rubra with a fleshy odor B) Respiratory rate of 16 breaths per minute C) Temperature of 101° F D) Pain rating of 2 on a scale from 0 to 10
C) Temperature of 101° F
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following? A) Retained placental fragments B) Hypertension C) Thrombophlebitis D) Uterine subinvolution
C) Thrombophlebitis
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A) Supine B) Lithotomy C) Upright D) Knee-chest
C) Upright Rationale: The use of any upright position helps to reduce the length of labor. Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy. The knee-chest position would assist in rotating the fetus in a posterior position.
Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor
C) Uterine atony, placenta previa, operative procedures
A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also complains of acute abdominal pain that is continuous. Which of the following would the nurse suspect? A) Amniotic fluid embolism B) Shoulder dystocia C) Uterine rupture D) Umbilical cord prolapse
C) Uterine rupture Rationale: Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? A) "I will use a soft toothbrush to brush my teeth." B) "I will call my health care provider if my stools are black and tarry." C) "I need to avoid drinking any alcohol." D) "I can take ibuprofen if I have any pain."
D) "I can take ibuprofen if I have any pain."
A woman developed abruptio placenta during the birth of her neonate. The nurse would monitor the client closely for changes. Which finding would be a cause for alarm? A) Severe uterine pain B) Inversion of the uterus C) Board-like abdomen D) Appearance of petechiae
D) Appearance of petechiae Rationale: A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with abruptio placentae.
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compares to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production
D) Are unable to shiver effectively to increase heat production
It is determined that a client's blood Rh is negative and her partner's is positive. To help It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse anticipates that the client will receive RhoGAM at which time?A) At 34 weeks' gestation and immediately before discharge B) 24 hours before delivery and 24 hours after delivery C) In the first trimester and within 2 hours of delivery D) At 28 weeks' gestation and again within 72 hours after delivery
D) At 28 weeks' gestation and again within 72 hours after delivery
As part of an inservice program, a nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse correctly identifies this as postpartum: A) Depression B) Psychosis C) Bipolar disorder D) Blues
D) Blues
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A) Marijuana B) Alcohol C) Heroin D) Cocaine
D) Cocaine
When assessing a woman at follow-up prenatal visits, the nurse would anticipate which of the following to be performed? A) Hemoglobin and hematocrit B) Urine for culture C) Fetal ultrasound D) Fundal height measurement
D) Fundal height measurement
A pregnant woman needs an update in her immunizations. Which of the following vaccinations would the nurse ensure that the woman receives? A) Measles B) Mumps C) Rubella D) Hepatitis B
D) Hepatitis B
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? A) Hypovolemia B) Trauma C) Hemorrhage D) Infection
D) Infection
A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? A) Applying pressure to the umbilical cord to remove the placenta B) Administering broad-spectrum antibiotics C) Manually removing the placenta at delivery D) Inspecting the placenta after delivery for intactness
D) Inspecting the placenta after delivery for intactness Rationale: After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A) Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D) Instructing her to apply ice packs to both breasts every other hour
D) Instructing her to apply ice packs to both breasts every other hour
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A) Posterior position B) Firm C) Closed D) Shortened
D) Shortened
A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like
D) Slit-like
Which of the following would alert the nurse to the possibility of respiratory distress in a newborn? A) Symmetrical chest movements B) Periodic breathing C) Respiration's of 40 breaths/minute D) Sternal retractions
D) Sternal retractions
A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which condition would the nurse most likely find as the most common cause? A) Labor augmentation B) Cervical or vaginal lacerations C) Uterine inversion D) Uterine atony
D) Uterine atony
After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature? A) Hearing B) Touch C) Taste D) Vision
D) Vision
