Role Transition modules 1-6 self check questions

Things to Remember (Maternity: Postpartum Care)

- The priority nursing care of the mother after birth is to promote firm uterine contraction, promote comfort, and promote parent-infant attachment. -To most accurately determine the amount of lochial flow, weigh the perineal pad before and after use and keep track of the time between pad changes. -Encourage fluids in the postpartum period because of the dehydrating effects of the labor and delivery process. If the client's temperature rises higher than 100.4° F (38°C), health care provider is notified, because this could indicate infection. -In the postpartum period, a pulse rate greater than 100 beats/min could indicate blood loss or infection. -If the blood pressure drops, bleeding or hypovolemia should be suspected. -Women may ovulate without menstruating, so breastfeeding should not be considered a form of birth control. -All women should be assessed for depression during pregnancy and in the postpartum period.

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson theory of psychosocial development. According to this theory, which choice represents the primary developmental task of the child? 1. To master useful skills and tools 2. To gain independence from parents 3. To develop a sense of trust in the world 4. To develop a sense of control over self and body functions

1. To master useful skills and tools Rationale

Priority Points to Remember! (Early Adulthood, Middle Adulthood,and Later Adult)

-Aging is a natural process that is common to all individuals. -The young adult tends to ignore physical symptoms and postpone seeking health care. -The task of middle adulthood is to achieve generativity. -Age-related changes can increase the older client's risk for injury. -Excess bathing may result in dryness, itching, and skin disruption. -Regular exercise helps maintain muscle tone and strength and improves circulation. -The reduced respiratory function associated with aging places the client, particularly the immobile client, at risk for pneumonia. -Age-related decline in immune system function increases the older client's risk of infection. -Age-related changes can alter the mechanism of medication absorption, putting the client at risk for adverse medication reactions. -One common sign of an adverse reaction to a medication in the older client is an acute change in mental status. -Any suicide threat by an older client should be taken seriously.

Things to Remember (Maternity)

-Fertilization occurs in the upper region of the fallopian tubes. -Most substances in maternal blood can be transferred to the fetus. -The umbilical cord contains two arteries and one vein. -Positive signs of pregnancy include auscultation of the fetal heart rate, active fetal movements palpable by the examiner, and the outline of the fetus on ultrasound. -The gravid uterus partially occludes the vena cava and descending aorta when the mother lies in a supine position, sometimes resulting in supine hypotensive syndrome; this may be prevented or corrected by positioning the mother in a lateral position. -During the second and third trimesters (weeks 18-30), fundal height in centimeters approximately equals the fetus's age in weeks, plus or minus 2 cm. -An increase of about 300 calories per day is needed during pregnancy. -An increase of about 500 calories per day is needed during lactation. -A diet high in folic acid and folic acid supplementation are important. -The pregnant woman should drink at least eight to ten 8-oz (235ml) glasses of fluid each day, of which four to six glasses should be water. -The nonstress test reveals whether the fetal heart rate accelerates when the fetus moves. -The contraction stress test is used to evaluate the response of the fetal heart to recurrent short interruptions in placental blood flow and oxygen supply that occur with uterine contractions. Page 75 of 82

Things to Remember (Maternity: Intrapartum care)

-Normal labor is characterized by a consistent progression of contractions, cervical dilation and effacement, and fetal descent. -In true labor, contractions increase in duration and intensity. -In false labor, contractions are irregular and do not produce dilation, effacement, or descent. -If fetal bradycardia or tachycardia occurs, change the position of the mother and administer oxygen, then assess the mother's vital signs; the health care provider is notified immediately. -Decreased variability may result from fetal hypoxemia, acidosis, or the use of certain medications. -Interventions for late decelerations include improving placental blood flow and fetal oxygenation. -Assess the color of the amniotic fluid if the membranes have ruptured, because meconium-stained fluid may indicate fetal distress. -If the membranes rupture, the priority nursing action is to assess the fetal heart rate. -Monitor lochia discharge. Lochia may be red and moderate in amount in stage 4. -General anesthesia presents a danger of respiratory depression, vomiting, and aspiration. -An oxytocin infusion is discontinued if uterine contraction frequency is less than 2 minutes or duration is longer than 90 seconds, or if fetal distress is noted.

Points to Remember (Family systems and Family Dynamics)

-The family strongly influences the health behaviors of its members, and the health status of each individual influences how the family unit functions and its ability to achieve goals. -The nurse should identify the family structure and roles of the family members and assess family dynamics to formulate a plan of care. -The nurse must recognize the cultural and religious influences that affect family function. -Until the young toddler feels secure in the affection of his or her parents, expecting the toddler to welcome a newborn infant into the family is not realistic. -Older children often enjoy taking responsibility for the care of a younger sibling. -Adolescents are more likely to take risks with sexual activity because they believe that the chance of becoming pregnant is small. -Several factors, including the need or desire for contraception, personal preference, cultural and religious beliefs and practices, effectiveness, and safety, should be considered in the choice of a method of birth control. -The nurse must identify the expected outcomes for family planning and discuss the contraindications for the chosen method of contraception. -Oral contraceptives are contraindicated in women with a history of thrombophlebitis, thromboembolitic disorders, stroke, or coronary artery disease; other risk factors for thrombosis; known or suspected breast carcinoma; benign or malignant liver tumors; undiagnosed abnormal genital bleeding. They are also contraindicated in pregnant women. -Oral contraceptives should be used with caution by women with diabetes mellitus, women who are smokers, woman who have risk factors for cardiovascular disease (e.g., hypertension, obesity, hypercholesterolemia), and women anticipating elective surgery in which postoperative thrombosis might be expected. -Most condoms are made of latex, which is impermeable to bacteria and viruses; therefore, in addition to protecting against pregnancy, latex condoms protect against STIs. (Polyurethane condoms also protect against STIs, but condoms made from lamb intestines are permeable to viruses and do not protect against STIs.) -Because of the risk of toxic shock syndrome, a diaphragm should not remain in place for more than 24 hours. -Natural family planning methods involve the use of physiological cues to predict ovulation; coitus is avoided when conditions are favorable for fertilization. -Natural family planning methods are acceptable to most religious groups because they do not involve the use of medications, chemicals, or devices.

Things to Remember (Care of the newborn)

-The priority nursing care of the newborn after birth is to promote normal respiration, maintain normal body temperature, place identification bracelets on the newborn infant and mother, and promote attachment. -The newborn's Apgar score is assessed and recorded at 1 and 5 minutes after birth. -An intramuscular dose of vitamin K is prescribed to prevent hemorrhagic disorders; administer in the lateral aspect of the middle third of the vastus lateralis muscle. -Eye medication is prescribed to prevent ophthalmia neonatorum; administer within 1 hour of birth. -When performing the physical examination, keep the newborn warm; begin with general observations and then perform assessments that are least disturbing to the newborn first. -Cold stress causes oxygen consumption and energy to be diverted from maintaining normal brain cell function and cardiac function, resulting in serious metabolic and physiological conditions. -Acrocyanosis (peripheral cyanosis) is normal in the first few hours after birth and then may be noted intermittently for next 7 to 10 days. -Slight tremors may be a common finding but may also signal hypoglycemia or drug withdrawal. -Normal, or physiological, jaundice appears after the first 24 hours in full-term newborns and after the first 48 hours in premature newborns; jaundice occurring before this time (pathological jaundice) may indicate early hemolysis of red blood cells and must be reported to the health care provider. -First voiding should occur within 24 hours of birth. -Meconium stool, which is greenish black, with a tarlike consistency, is usually passed during the first 24 hours of life. - The mother must be taught to check the identification of any person who comes to remove the baby from her room as one of the precautions against newborn abduction (e.g., nurses must be wearing photo identification or some other security badge). Page 41 of 48

A nurse checking the vital signs of an older client notes that the client's resting heart rate is 60 beats per minute. Which action should the nurse take on the basis of this finding? 1. Document the finding. 2. Recheck the heart rate in 30 minutes. 3. Assess the client for signs of infection. 4. Contact the health care provider to report the heart rate

1. Document the finding. Rationale: In an adult client, a heart rate slower than 60 beats per minute indicates bradycardia and a heart rate faster than 100 beats per minute indicates tachycardia. The heart rate decreases with age, so a rate of 60 beats per minute is within the normal parameters. Therefore, because the rate presented in the question constitutes a normal finding, the nurse would document the heart rate. On the basis of the data in the question, the other options are unnecessary.

After a year, Marilyn calls the nurse to report that she may be pregnant. She says, "I missed 2 days of pills, so we've been using the rhythm method. Do I still take today's pill?" Which responses by the nurse are appropriate? Select all that apply. 1. "Can you stop by the office this afternoon for a pregnancy test?" 2. "Keep taking the birth control until your pregnancy is confirmed." 3. "The rhythm method is quite accurate. You probably are not pregnant." 4. "Wait a week, and if you still think you're pregnant stop the birth control pill." 5. "Do not take the birth control until you are tested in the office for pregnancy."

1. "Can you stop by the office this afternoon for a pregnancy test?" 5. "Do not take the birth control until you are tested in the office for pregnancy." Rationale Pregnancy, or possible pregnancy, is a contraindication to the use of oral contraceptives. The client should be told to stop taking the contraceptive until pregnancy is confirmed or ruled out. The rhythm method, though commonly used, is not always effective, because ovulation is often irregular. The nurse cannot determine whether the client is pregnant with just a telephone conversation. A pregnancy test should be performed as soon as possible.

The next day, the newborn's blood type comes back as A-positive. Annie is type B-negative. The obstetrician prescribes an intramuscular dose of Rho(D) immunoglobulin (RhoGAM) for Annie. The nurse explains the purpose of the RhoGAM, and prepares the injection. Which statement by Annie reflects a need for further education? 1. "My baby will need a dose of this medication, too." 2. "My husband doesn't need to have a dose of this medication." 3. "This shot will prevent a reaction in my body from the blood of my baby." 4. "This shot will make it safer for my future babies if they have a positive blood type."

1. "My baby will need a dose of this medication, too." Rationale Rho(D) immunoglobulin (RhoGAM) is given within 72 hours of delivery to prevent antibody sensitization in an Rh-negative woman who has given birth to an Rh-positive infant, in whom fetomaternal transfusion may have occurred. The immune globulin promotes the destruction of any fetal Rh-positive cells that may have entered the mother's bloodstream before her body has had a chance to form antibodies against them. As a result, future pregnancies with Rh-positive infants will not be at risk for hemolysis. Only the mother receives the injection.

A nurse performing an initial assessment of a newborn who is awake and alert counts the infant's apical heart rate and obtains a rate of 130 beats/min. Based on this finding, which action should the nurse take? 1. Documenting the finding 2. Contacting the pediatrician 3. Reassessing the heart rate in 5 minutes 4. Stimulating the infant and reassessing the heart rate

1. Documenting the finding Rationale The normal heart rate of a newborn infant is 100 to 160 beats/min. Therefore the nurse would document the finding. The other options are incorrect and unnecessary.

The nurse is assessing Mrs. Valenti's nutritional status. Which statements by Mrs. Valenti indicate a risk for malnutrition? Select all that apply. 1. "Sometimes I have to make myself eat." 2. "My weight stays about the same each week." 3. "Food just doesn't taste the same as it used to." 4. "I have to wear my dentures to chew my food." 5. "Sometimes I have trouble swallowing my food." 6. "I try to eat fruits and vegetables with each meal."

1. "Sometimes I have to make myself eat." 3. "Food just doesn't taste the same as it used to." 5. "Sometimes I have trouble swallowing my food." Rationale Several factors - including dysphagia, decreased enjoyment of food because of a diminished sense of taste, and a lower motivation to eat - may increase the risk of malnutrition in an older adult. Many older adults require dentures to eat, but this is only a problem if they are ill fitting. A stable weight and consumption of several servings of fruits and vegetables every day are signs of good nutrition.

A nurse notes documentation in the medical record that a woman in labor is at +1 station. Based on this finding, what does the nurse determine is the presenting part of the fetus? 1. 1 cm below the ischial spines 2. 1 cm above the ischial spines 3. At the level of the ischial spines 4. Above the level of the ischial spines

1. 1 cm below the ischial spines Rationale Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. Station is expressed in centimeters above or below the spines. When the presenting part is 1 cm below the ischial spines, the station is noted as +1. When the presenting part is 1 cm above the ischial spines, the station is noted as -1. When the presenting part is at the level of the ischial spines, the station is noted as zero.

Which action should the nurse implement first to treat the dehydration? 1. Administering oral Pedialyte 2. Instituting NPO (nothing-by-mouth) status 3. Encouraging Mrs.Valenti to drink sips of water 4. Starting an intravenous (IV) line and administer IV fluids

1. Administering oral Pedialyte Rationale Oral hydration is the first approach to the treatment of dehydration if the client is able to ingest fluids. Sport drinks, though high in sugar, are often recommended over tap water because are easily absorbed by the stomach, are generally palatable to clients, and will more quickly correct the dehydration. Pedialyte and other commercial fluid and electrolyte solutions are also available. The administration of IV fluids is a last-resort approach. There is no reason to maintain Mrs.Valenti on NPO status; in fact, this could worsen the dehydration.

Oral contraceptive therapy has been prescribed for a client with a history of seizures who is taking phenytoin. Which information should the nurse provide to the client after reviewing the new prescription? 1. An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives. 2. An increased dosage of the phenytoin must be prescribed because phenytoin reduces the effectiveness of the oral contraceptive. 3. The primary care health care provider will need to increase the dosage of the phenytoin. 4. The effect of the phenytoin will be magnified while the client is taking the oral contraceptive

1. An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives. Rationale: Phenytoin is an anticonvulsant that reduces the effectiveness of oral contraceptives. When a client is taking a medication that diminishes the effectiveness of oral contraceptives, an increased dosage of the oral contraceptive may be required. An increased dosage of the phenytoin would not be necessary; additionally, this could be harmful to the client and lead to phenytoin toxicity. The effect of the phenytoin is not magnified while the client is taking the oral contraceptive.

After 2 days Mrs. Valenti is feeling better, and the discharge planner begins arranging for her to be sent back to the residential home. The nurse gives report to the nurse at the home, and Mrs. Valenti arrives there late in the afternoon. Which measures should the nurse at the residential home implement to prevent recurrence of dehydration? Select all that apply. 1. Assessing urine output 2. Offering fluids with meals only 3. Offering fluids other than water, such as coffee and iced tea 4. Monitoring her pulse and respiratory rates, and blood pressure 5. Find out what fluids she prefers besides water and offer those

1. Assessing urine output 4. Monitoring her pulse and respiratory rates, and blood pressure 5. Find out what fluids she prefers besides water and offer those Rationale Measures to help prevent dehydration in older adults include monitoring pulse rate and respiration for increases and the blood pressure for a decrease, all of which may indicate dehydration. In addition, urine output should be monitored, because decreased urine output may indicate dehydration. Fluids should be offered every hour, including with the evening snack, and the nurse should find out what fluids are preferred and offer those, with the exception of drinks containing caffeine (e.g., coffee and iced tea), which acts as a diuretic.

Which priority action would the nurse take after attaching an external electronic fetal monitor to a pregnant client? 1. Checking the fetal heart rate 2. Discussing the labor process with the client 3. Assessing the frequency of the contractions 4. Documenting the time that the monitor was attached

1. Checking the fetal heart rate Rationale Assessing the fetal heart rate is the priority action after an electronic fetal monitor is attached to a pregnant client. Although assessment of the frequency of contractions is important, it is not the priority. Likewise, documenting and discussing the labor process with the client are components of the plan of care but are not the priority

A nurse is preparing to apply erythromycin ophthalmic ointment to a newborn's eyes. Which action should the nurse plan to take? 1. Cleansing the infant's eyes before applying the ointment 2. Applying the ointment to the upper conjunctival sac of each eye 3. Rinsing the excess ointment from the eye using normal saline solution 4. Applying the ointment from the outer canthus to the inner canthus of the eye

1. Cleansing the infant's eyes before applying the ointment Rationale The infant's eyes are cleansed before the administration of eye ointment. The ointment is placed in the lower conjunctival sac of each eye and deposited from the inner canthus to the outer canthus. The ointment is not rinsed from the eye, although it may be wiped from the outer eye area after 1 minute.

A client discussing family planning methods with the nurse tells the nurse that she uses the calendar method because her menstrual periods are regular. Which information about the reliability of this method should the nurse provide to the client? 1. It is unreliable. 2. It is extremely reliable if menstrual periods are regular. 3. If it has prevented pregnancy so far, it is a reliable method. 4. It is very reliable if the basal body temperature method is also used.

1. It is unreliable. Rationale The calendar method is based on the fact that ovulation occurs approximately 14 days before the onset of menses. It is unreliable because many factors, such as illness or stress, can affect the time of ovulation. In the basal body temperature method, the woman charts her temperature each morning before getting out of bed. The basal body temperature may decrease slightly before ovulation and then increase slightly with ovulation. This method, which is not reliable because errors are frequent, is often used along with other methods. Therefore the other options are incorrect.

Penny's labor continues, and she is now at 9 cm of dilation. During contractions, the fetal heart monitor shows the patterns depicted on the graph. What does the nurse determine? Click to enlarge 1. No action is required 2. The oxytocin infusion must be stopped 3. Penny should be moved into a side-lying position 4. Oxygen, at a rate of 8 to 10 L/min by way of a face mask, needs to be administered

1. No action is required Rationale Early deceleration of the fetal heart rate (FHR) is an obvious gradual decrease and then return to baseline that is associated with uterine contractions. Early decelerations are considered benign, and nursing interventions are not required. Moving the mother into a side-lying position, administering oxygen, and stopping the oxytocin infusion are interventions that would be needed for late or variable decelerations of the FHR, which may indicate fetal distress.

A nurse has completed a family assessment and is documenting the information obtained during the interview. The household comprises a father, a mother, one son, and two daughters. What family type should the nurse document? 1. Nuclear 2. Blended 3. Extended 4. Multi-adult

1. Nuclear Rationale: A nuclear family consists of two partners, heterosexual or homosexual, and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint-living situation. An extended family includes relatives such as aunts, uncles, grandparents, and cousins in addition to the nuclear family. A multi-adult family is one in which more than one adult is living in a household.

A nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. Which outcomes are desired and should be selected by the nurse for the plan of care? Select all that apply. 1. The client is not shivering. 2. The client's body temperature is 98° F (36.7°C). 3. The client's fingers and toes are cool to touch. 4. The client remains in a fetal position when in bed. 5. The client complains of coolness in the hands and feet only.

1. The client is not shivering. 2. The client's body temperature is 98° F (36.7°C). Rationale: Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include warm hands and feet; relaxed, uncurled body; body temperature higher than 97° F; absence of shivering; and no complaints of feeling cold.

A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. The nurse should tell the client: 1. To increase her daily intake of high-fiber foods 2. That this is a normal occurrence during pregnancy 3. To take the iron supplement every other day instead of every day 4. To start taking an oral laxative daily until the constipation resolves

1. To increase her daily intake of high-fiber foods Rationale Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.

A nurse assessing a newborn's reflexes tests the Babinski (plantar) reflex. The nurse notes that when the reflex is elicited, the infant's toes hyperextend and the big toe dorsiflexes. How should the nurse document this finding? 1. Positive 2. Negative 3. Unresponsive 4. Depressed

1. Positive Rationale To elicit the Babinski reflex, the nurse begins at the heel of the foot and strokes upward along the lateral aspect of the sole of the foot, then moves the finger across the ball of the foot. In the characteristic response, all toes hyperextend and the big toe dorsiflexes. This is recorded as a positive sign. Although the response depends on general muscle tone and condition of the infant, an absence of response requires neurological evaluation. Therefore the other options are incorrect.

Joanna asks the nurse about toilet-training Joel. She is not sure whether he is ready and anticipates that he will throw a temper tantrum if she begins to toilet-train him. The nurse tells Joanna to watch for certain signs and readiness to toilet-train. What are they? Select all that apply 1. Ability to remove clothing 2. Refusal to sit on the toilet 3. Impatience with a wet diaper during the day 4. An increased number of wet diapers during the day 5. A dry diaper when the child wakes from a nap

1. Ability to remove clothing 3. Impatience with a wet diaper during the day 5. A dry diaper when the child wakes from a nap Rationale Signs of readiness for toilet training include the ability to stay dry for 2 hours; waking dry from a nap; the ability to sit, squat, and walk; the ability to remove clothing; the ability to recognize the urge to defecate or urinate; the ability to sit on the toilet for 5 to 10 minutes without fussing or getting off; impatience with a wet or soiled diaper; and willingness to please the parent.

Which statement by Joanna reflects a need for further information? (Select all that apply) 1. He's too young to get cavities 2. I will use the car seat overtime we drive somewhere 3.He will probably swallow gum instead of just chewing it 4. He can eat most foods as long as I cut them into round pieces 5. I will apply sunscreen if we are outside for more than an hour 6. We need to make sure that our cleaning supplies are in a locked cabinet.

1. He's too young to get cavities 4. He can eat most foods as long as I cut them into round pieces 5. I will apply sunscreen if we are outside for more than an hour Rationale Cavities can occur in teeth of a person of any age, and parents of toddlers should be taught how to care for a toddler's teeth, and be provided with information about foods that are highly likely to cause cavities. Toddlers are at a very high risk for poisoning, and a major cause is improper storage of harmful items. Therefore, locking cleaning supplies and other toxic items is essential, along with constant vigilance in supervising the toddler. Toddlers can chew, but may have problems with large pieces of food. Food should be cut into small pieces; round pieces may be easily aspirated and are choking hazards. It takes practice for a toddler to learn how to chew gum, but not to swallow it. Sunscreen should be applied before any exposure to sunlight. Parents should always use a care safety seat, even if the trip is short.

Joanna ask the nurse how to deal with Joel's bedtime temper tantrums. Which strategy should the nurse recommend to Joanna? 1. Safely isolating Joel and ignoring temper tantrums 2. Giving in to Joel's demands and allowing him to stay up a little longer 3. Telling Joel that he will be punished if the temper tantrum continues 4. Telling Joel that a favorite toy will be taken away if the temper tantrum doesn't stop

1. Safely isolating Joel and ignoring temper tantrums Rationale Temper tantrums, a common toddler response to anger and frustration, are often a result of thwarted attempts at exerting mastery and autonomy. Generally the most effective method of handling a tantrum is to safely isolate and ignore the child. The child should learn that nothing, not even attention, is gained from a tantrum. Giving in to the child's demands or scolding and punishing the child will only worsen the behavior. Toddlers stop using tantrums when they do not achieve their goals and as their verbal skills increase.

A nurse monitoring lochial flow in a woman who delivered 2 hours earlier notes that the client's perineal pad shows drainage measuring less than 1 inch in a 1-hour period. How should the nurse report the lochial flow? 1. Scant 2. Light 3. Heavy 4. Excessive Submit

1. Scant Rationale Lochia is the discharge from the uterus in the postpartum period, consists of blood from the vessels of the placental site and debris from the decidua. The following guide may be used to determine the amount of flow: scant, less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light, less than 10 cm (4 inches) on pad in 1 hour; moderate, less than 15 cm (6 inches) on pad in 1 hour; heavy, saturation of pad in 1 hour; and excessive, saturation of pad in 15 minutes.

A pediatric nurse id developing nursing care plans on the basis of Erik Erikson's stages of psychosocial development. Using Erikson's stages of psychosocial development, number the psychosocial crises in order of occurrence on the basis of development stage, from birth (1) to 20 years of age (5). 1. Industry vs Inferiority 2. Identity vs role confusion 3. Initiative vs guilt 4. Autonomy vs shame and doubt 5. Trust vs mistrust

1. Trust vs Mistrust 2. Autonomy vs shame and doubt 3. Initiative vs guilt 4. Industry vs Inferiority 5. Identity vs role confusion Rationale: Erikson describes the human life cycle as series of eight ego-developmental stages, from both to death. Each stage presets a psychosocial crisis and focuses on psychosocial tasks that are accomplished. These orderly stages and associated psychosocial crises are: trust vs mistrust(infancy), autonomy vs shame and doubt (toddler), industry vs inferiority(school-aged), and identifies intimacy vs role confusion (adolescent). Erikson also identifies intimacy vs isolation for early adulthood, generatively vs stagnation for middle adulthood, and integrity vs despair for later adulthood (older adult)

A middle-aged couple comes to the family planning center to discuss methods of contraception and asks about sterilization. As a means of determining whether this method of sterilization is appropriate, which question should the nurse ask the couple? 1. "Has either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Does either of you have diabetes mellitus?" 4. "Does either of you have problems with high blood pressure?"

2. "Do you plan to have any other children?" Rationale Sterilization is a method of contraception for couples who have completed their families. It should always be considered a permanent end to fertility, because reversal surgery is difficult and expensive and may not be covered by insurance. Additionally, reversal surgery is not always successful, and it increases the risk of ectopic pregnancy. Therefore the nurse would ask the couple about plans for having children in the future to help determine the correct method of contraception. The assessment questions noted in the other options may be appropriate to ask a client who may be undergoing surgery, but they are not specifically related to sterilization.

The lactation consultant nurse visits Annie to discuss breastfeeding and to observe as Annie breastfeeds her baby. The nurse discusses mastitis, its signs and symptoms, how to prevent it, and what to do if it occurs. Which statements by Annie reflect understanding of the information that is being presented? Select all that apply. 1. "It won't hurt to miss a few feedings if I'm too tired." 2. "I'll wash my nipples carefully before and after feedings." 3. "I should expect to have sore, cracked nipples when starting to breastfeed." 4. "If I get mastitis, I'll have to stop breastfeeding from that side until it is healed." 5. "If my nipples are sore, I should apply warm water compresses before breastfeeding." 6. "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours."

2. "I'll wash my nipples carefully before and after feedings." 5. "If my nipples are sore, I should apply warm water compresses before breastfeeding." 6. "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours." Rationale Mastitis, a breast infection, may affect one or both breasts. It may be prevented with the use of proper technique and positioning for breastfeeding, preventing the development of cracked nipples, and emptying the breasts at regular intervals by means of breastfeeding, manual expression, or breast pumping. Cleanliness is also important. If mastitis occurs, breastfeeding is still recommended, because it is important to empty the breasts. Missed feedings can contribute to mastitis. The nipples may be sore (but not cracked) at the beginning of breastfeeding, and warm water compresses may be comforting before breastfeeding.

The health care provider performs a physical examination and gives Marilyn a prescription for an oral contraceptive. The nurse then provides information to Marilyn about how to take the medication. Which statement by Marilyn indicates a need for further information? 1. "If I miss a pill, I should take it as soon as I remember." 2. "Once I start taking the pill, I don't need to worry about getting pregnant." 3. "f I miss a period and think that I might be pregnant, I should stop taking the pill." 4. "I should use another contraceptive method during the first week of the first cycle of pills."

2. "Once I start taking the pill, I don't need to worry about getting pregnant." Rationale Because maintaining a constant hormone level is important for effectiveness, the woman using oral contraceptive must take a pill at the same time each day. Unless a woman begins the pills during the first 7 days of the menstrual cycle, she should use another contraceptive method during the first week of the first cycle until blood hormone levels are established. If the woman misses a pill, she should take it as soon she remembers. If the woman misses a period and thinks that she might be pregnant, she should stop taking the pill and have a pregnancy test immediately.

A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? 1. 4 days 2. 10 days 3. 14 days 4. 21 days

2. 10 days Rationale Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.

A nonstress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? 1. Fetal well-being has been established. 2. A contraction stress test will be scheduled. 3. Placental function and oxygenation are adequate. 4. The results are inadequate and the nonstress test must be repeated.

2. A contraction stress test will be scheduled. Rationale A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if nonstress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.

A mother changing her newborn daughter's diaper notes the presence of a small amount of blood on the infant's labia. The mother is concerned and tells the nurse that the infant is bleeding from the vaginal area. After assessing the infant, what response does the nurse provide to the mother? 1. The pediatrician will need to check the infant. 2. A small amount of vaginal bleeding is normal. 3. The bleeding is nothing to be concerned about. 4. The bleeding is probably a result of trauma from the birth process

2. A small amount of vaginal bleeding is normal. Rationale In the full-term female infant, edema of the labia and a white mucous vaginal discharge are normal. A small amount of vaginal bleeding, known as pseudomenstruation, may occur as a result of the sudden withdrawal of the mother's hormones at birth. It is not a result of trauma. Because the finding is normal, the pediatrician will not need to check the infant. Telling the mother that the finding is nothing to be concerned about is not the most appropriate option, because it is nontherapeutic.

A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nägele's rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? 1. October 17, 2016 2. November 17, 2016 3. September 17, 2016 4. December 17, 2017

2. November 17, 2016 Rationale For Nägele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.

A nurse assists an obstetrician in performing an amniotomy on a woman admitted to the labor unit. Which action should the nurse take immediately after the procedure? 1. Helping the woman walk 2. Checking the fetal heart rate 3. Assisting the woman in bathing 4. Checking the woman's temperature

2. Checking the fetal heart rate Rationale Amniotomy is the artificial rupture of membranes that is performed by the health care provider to stimulate labor. The primary risk associated with amniotomy is that the umbilical cord will slip down in the gush of fluid and become compressed between the fetal presenting part and the woman's pelvis, obstructing blood flow to and from the placenta and reducing gas exchange. Therefore the nurse's action immediately after the procedure would be to check the fetal heart rate. Although the nurse would monitor the woman's temperature and help the woman bathe, these are not immediately necessary actions. The woman would not be allowed to walk unless this has specifically been prescribed.

A nurse monitoring the fetal heart rate (FHR) pattern of a woman in the first stage of labor whose cervix is dilated 6 cm notes the presence of early decelerations. Based on this finding, what action should the nurse take? 1. Contacting the nurse-midwife 2. Continuing to monitor the FHR pattern 3. Administering oxygen at 10 L by face mask 4. Preparing the woman for immediate delivery

2. Continuing to monitor the FHR pattern Rationale Early deceleration of the FHR is a visually apparent gradual decrease in and return to baseline FHR that occurs in response to fetal head compression during a contraction. It is a normal and benign finding, and therefore no intervention is necessary.

Which findings are normal age-related physiological changes? Select all that apply. 1. Increased heart rate 2. Diminished visual acuity 3. Decline in long-term memory 4. Increased susceptibility to urinary tract infections 5. Increased incidence of awakening after onset of sleep

2. Diminished visual acuity 4. Increased susceptibility to urinary tract infections 5. Increased incidence of awakening after onset of sleep Rationale Anatomic changes in the eye affect the older individual's visual ability acuity, sometimes leading to problems in carrying out activities of daily living. Light adaptation is diminished and visual fields reduced. The heart rate slows and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Sleep pattern changes are common with increasing age. Older persons generally experience an increased incidence of awakening after sleep onset.

A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? 1. The umbilical cord holds two veins and one artery. 2. Fetal blood circulation takes place strictly in the placenta. 3. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. 4. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.

2. Fetal blood circulation takes place strictly in the placenta. Rationale The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.

The nurse completes Janice's obstetric history. How does the nurse record Janice's history of gravidity and parity? 1. Gravida 2, para 2 2. Gravida 3, para 2 3. Gravida 3, para 3 4. Gravida 2, para 3

2. Gravida 3, para 2 Rationale Gravida refers to the number of pregnancies, including the current one. Parity is the number of births (not the number of fetuses - e.g., twins) carried past 20 weeks at delivery, whether or not the fetus was born alive. Because this is the client's third pregnancy, her gravidity is 3. Because Janice is in her first trimester of this pregnancy and also has one son who was born at 40 weeks' gestation and one daughter who was born at 36 weeks' gestation, her parity is 2.

A home-care nurse is providing information to an older client about measures to prevent constipation. Which action should the nurse tell the client to take? 1. Take an oral laxative daily. 2. Include bran in the daily diet. 3. Eat less fresh fruit each day. 4. Keep fluid intake to 1000ml per day

2. Include bran in the daily diet. Rationale: Diet is a common cause of constipation in older adults. Usually a lack of certain foods, rather than the consumption of certain foods, leads to the problem. Fresh fruits and vegetables contain natural laxatives and should be included in the daily diet. Another dietary cause of constipation is the lack of fiber or bulk and reduced fluid intake. Therefore the client should include fiber, such as bran, in the diet and should drink 2000 mL of fluid daily unless it is contraindicated because of a medical condition. Constipation may be caused by overuse or improper use of laxatives stemming from the client's excessive concern about the frequency of bowel movements. The client would not be instructed to take a laxative on a daily basis.

A nurse taking the vital signs of a client who delivered a healthy newborn infant 4 hours ago notes that the client's oral temperature is 101.2° F (38.4°C). Which action would be appropriate? 1. Documenting the findings 2. Notifying the health care provider 3. Retaking the temperature rectally 4. Telling the client that the temperature at this level is expected at this time

2. Notifying the health care provider Rationale Temperatures up to 100.4° F (38.0° C) in the 24 hours after birth are often related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. However, a temperature higher than 100.4° F indicates an infection, and the health care provider should be notified. Although the nurse also would document the findings, the appropriate action would be to contact the health care provider. There is no useful reason for taking the temperature rectally. Telling the client that her increased temperature is expected at this time is incorrect.

A nurse is conducting a psychosocial assessment of a 40-year-old client. Which findings would the nurse recognize as a sign of emotional health in a person in middle adulthood? 1. The client is establishing intimate bonds of love and friendship. 2. The client provides guidance during interactions with his children. 3. The client verbalizes readiness to assume parental responsibilities. 4. The client is making decisions concerning career, marriage, and parenthood.

2. The client provides guidance during interactions with his children. Rationale: Middle adulthood is the period between the middle to late thirties and the middle sixties. According to Erikson's developmental theory, the psychosocial crisis of middle adulthood is generativity versus stagnation. The developmental task is to fulfill life's goals involving family, career, and society; successful resolution is demonstrated by the willingness to give to and care for others and to guide others. Middle adults can achieve generativity with their own children or the children of close friends or through other social interactions with the next generation. Making decisions about career, marriage, and parenthood; verbalizing readiness to assume parental responsibilities; and establishing intimate bonds of love and friendship are signs of emotional health in the early adult years.

A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? 1. The client is definitely pregnant. 2. The nurse-midwife noted softening of the cervix. 3. The client exhibits a presumptive sign of pregnancy. 4. The nurse-midwife noted a violet coloration of the cervix.

2. The nurse-midwife noted softening of the cervix Rationale In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.

A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? 1. She must come to the clinic to be checked. 2. This is an expected occurrence during pregnancy. 3. This is frequently the first sign of a breast infection. 4. She should notify the nurse-midwife of this finding

2. This is an expected occurrence during pregnancy. Rationale Colostrum, the creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples as early as 16 weeks' gestation. This is an expected occurrence during pregnancy. It is not necessary for the client to notify the nurse-midwife or to report to the clinic to be checked. It is not a sign of infection.

A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? 1. Week 1 2. Week 5 3. Week 8 4. Week 9

2. Week 5 Rationale By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore the other options are incorrect.

Which instructions should the nurse provide to the mother? 1. Place the child in the back seat of the var in a booster seat? 2. Place the child in the back seats in a forward-facing convertible seat with a harness 3. Restrain the child in the passenger side of the front seat as long as an air bag is in place 4. Place the child in the back seat of the car in a forward-facing position using the car seat belt.

2. Place the child in the back seat in a forward-facing convertible seat with a harness Rationale The convertible restraint is used for toddlers and preschoolers. It is best that the child ride in a rear-facing position for as long as possible, to the highest height and weight allowed by the manufacturer of their convertible seat. Once a child has outgrown the rear-facing seat, a forward-facing seat with a full harness should be used for as long as the child fits. Booster seats are for older children who have outgrown their forward-facing car safety seats. Air bags can be harmful or even lethal to small children.

What should the nurse tell Joanna? 1. Avoid letting Joel take any daytime naps 2. Provide a quiet activity for 30 minutes before bedtime 3.Providing a high-carbohydrate snack before bedtime to promote sleep 4. Allow the stalling tactics for 30 minutes, then tell Joel that he mist go to bed

2. Provide a quiet activity for 30 minutes before bedtime Rationale Toddlers often resist going to bed by stalling or even throwing temper tantrums to postpone the event. Firm, consistent limits are needed when toddlers try stalling tactics. Warning the child a few minutes before it is time for bed may reduce bedtime protests. Winding down with a quiet activity for 30 minutes before bedtime also helps the toddler prepare for sleep. Bedtime rituals are important and should be followed consistently. Daytime naps do not need to be avoided; a balance of activity, rest, and sleep is important. Avoiding high-carbohydrate snacks and excitement before bedtime promotes relaxation.

A sexually active single female client is discussing methods of contraception with the family planning nurse. The client tells the nurse that her primary concern is avoiding contracting sexually transmitted infections (STIs). In responding to the client, which method of protection does the nurse say provides the best protection against many STIs? 1. A diaphragm 2. A cervical cap 3. A latex condom 4. An intrauterine device (IUD)

3. A latex condom Rationale Latex condoms provide the best protection available (other than abstinence) against many STIs. A diaphragm and a cervical cap provide a mechanical barrier to prevent the passage of sperm into the uterus but do not provide protection against STIs. An IUD, which is inserted into the uterus, provides no protection against STIs.

The nurse obtains information about Marilyn's health history. What is the most important question for the nurse to ask Marilyn to elicit data related to the contraindications to oral contraceptives? 1. "Are you dieting?" 2. "Did you have acne as an adolescent?" 3. "Have you ever had thrombophlebitis?" 4. "Do you have a family history of kidney disease?"

3. "Have you ever had thrombophlebitis?" Rationale Oral contraceptives are contraindicated in women with or with a history of thrombophlebitis, thromboembolitic disorders, stroke, or coronary artery disease and in women with other risk factors for thrombosis. They are also contraindicated during pregnancy and in women with known or suspected breast carcinoma, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumor, or undiagnosed genital bleeding. Dieting and a family history of kidney disease are not contraindications to the use of oral contraceptives. Oral contraceptives may improve acne.

Phenytoin is an anticonvulsant that reduces the effectiveness of oral contraceptives. When a client is taking a medication that diminishes the effectiveness of oral contraceptives, an increased dosage of the oral contraceptive may be required. An increased dosage of the phenytoin would not be necessary; additionally, this could be harmful to the client and lead to phenytoin toxicity. The effect of the phenytoin is not magnified while the client is taking the oral contraceptive. 1. "I need to use spermicidal cream with the diaphragm." 2. "I shouldn't leave the diaphragm in for more than 24 hours." 3. "I have to insert the diaphragm immediately before intercourse." 4. "The diaphragm should stay in place for at least 6 hours after intercourse."

3. "I have to insert the diaphragm immediately before intercourse." Rationale When in place over the cervical os, the diaphragm blocks access of sperm to the cervix. Because the device does not fit tightly enough to completely block penetration of sperm, however, it must be filled with spermicidal jelly or cream before insertion. (Spermicide must be reapplied with repeated intercourse.) It may be inserted as long as 6 hours before intercourse. The diaphragm must remain in place for at least 6 hours after intercourse, but, because of the risk of toxic shock syndrome, it should not be left in place for more than 24 hours.

A nurse provides instructions to a breastfeeding mother about measures that will provide relief from breast engorgement. Which statement by the mother indicates an understanding of the instructions? 1. "I should switch to formula to feed my baby for 1 week." 2. "I need to stop breastfeeding until the engorgement resolves." 3. "I should apply warm packs to my breasts before each feeding." 4. "I need to apply ice packs to my breasts 20 minutes before a feeding."

3. "I should apply warm packs to my breasts before each feeding." Rationale When breast engorgement occurs, the breasts become edematous, hard, and tender, making feeding and even movement painful. The nurse should encourage the woman to begin breastfeeding early after delivery and to feed frequently as a means of preventing engorgement. The nurse would also teach the woman about the application of cold and heat, massage, and breastfeeding techniques. Cold is used after feeding to reduce edema and pain. Heat is applied just before feedings to increase vasodilation and milk flow. Massage of the breasts causes release of oxytocin and increases the speed of milk release. This decreases the length of time that the infant nurses on painful breasts.

At 30 weeks' gestation, Janice is seen in the maternity clinic for a follow-up visit. The nurse checks the fundal height. Which measurement does the nurse expect to see? 1. 20 cm 2. 26 cm 3. 30 cm 4. 34 cm

3. 30 cm Rationale From 22 weeks to term, the fundal height, which is measured in centimeters, is roughly equal (±2 cm) to the gestational age of the fetus in weeks. Therefore, because this client is at 30 weeks' gestation, her fundal height would be 30 (±2 cm). If fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause of the unexpectedly large uterine size. If fundal height is less than expected on the basis of gestational age, the estimated date of delivery must be confirmed. If the dates are accurate, further assessment may be necessary to determine whether the fetus' growth is inadequate.

Penny is admitted to the labor room in the first stage of labor. Which breathing pattern should the labor room nurse teach Gilbert so that he may coach Penny? 1. Pushing in short bursts when the urge is very strong 2. Exhaling small amounts of air through an open glottis during pushing 3. A deep inspiration and expiration at the beginning and end of each contraction 4. Taking a cleansing breath at the beginning of a contraction, holding her breath, then pushing as hard as she can for as long as possible

3. A deep inspiration and expiration at the beginning and end of each contraction Rationale Breathing exercises provide a focus during contractions, interfering with the transmission of pain sensation. During the first stage of labor, the client uses cleansing breaths (a deep inspiration and expiration at the beginning and end of each contraction), slow-paced breathing, modified-paced breathing, pattern-paced breathing, and breathing to prevent pushing. If the woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and fetal head.

Three weeks after the birth of her baby, Sara, Annie calls her obstetrician's office and speaks to the nurse. She tells the nurse that she has been feeling "hot" and very fatigued, even though she has been resting and has had her husband at home to help with the baby. The nurse asks Annie to come to the office for a checkup, and notes the assessment findings in Annie's record. Based on these assessment findings (click "Chart" below), what problem does the nurse suspect? 1. Mastitis 2. Influenza 3. Endometritis 4. Bladder infection

3. Endometritis Rationale Endometritis (infection of the uterine lining) is common during the postpartum period. Signs include fever, quickened pulse, nausea and anorexia, increased fatigue, lower abdominal pain, uterine tenderness, and increased lochial flow with a strong foul odor. Leukocytosis is also present. Mastitis is a breast infection; there is no information in Annie's record to indicate that mastitis is present. There are no specific data indicating that influenza (flu) is present. If a bladder infection were present, the urine would be cloudy and the urinalysis results would be abnormal.

A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? 1. Gravida 2, para 4 2. Gravida 3, para 5 3. Gravida 4, para 2 4. Gravida 5, para 3

3. Gravida 4, para 2 Rationale Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.

As Penny's labor progresses, the obstetrician performs another examination and concludes that Penny is in the second stage of labor. Which of these assessment findings should the nurse expect to note at this stage of labor? Select all that apply. 1. Descent of 1 to 2 cm 2. Pink to bloody mucus 3. Increase in bloody show 4. Increased urge to bear down 5. Cervical dilation of 10 cm with 100% effacement 6. Contractions 2 minutes apart, 90 seconds in duration

3. Increase in bloody show 4. Increased urge to bear down 5. Cervical dilation of 10 cm with 100% effacement 6. Contractions 2 minutes apart, 90 seconds in duration Rationale The second stage of labor is the stage during which the infant is born. The stage begins with cervical dilation of 10 cm and complete (100%) cervical effacement. The increase in bloody show, increased urge to bear down, and increased duration and frequency of contractions are part of the descent, or active pushing, phase of the second stage of labor. Mucus that is pink to bloody and descent of 1 to 2 cm are findings that are characteristic of the first stage of labor.

The mother of a newborn is upset because her newborn has a birthmark on the left side of the forehead. The mother, on being told that it is a nevus vasculosus (strawberry mark), asks the nurse whether the mark is permanent. What should the nurse tell the mother? 1. It is a permanent mark 2. It will need to be removed with surgery 3. It will disappear on its own by the early school years 4. It is nothing to be concerned about because it is so small

3. It will disappear on its own by the early school years Rationale Nevus vasculosus (strawberry mark) consists of enlarged capillaries in the outer layers of the skin. It is dark red and raised, with a rough surface, giving it a strawberry appearance. Usually located on the head, a nevus vasculosus may grow larger for 5 to 6 months but usually disappears by the early school years. No treatment is necessary.

Janice asks the nurse about her expected date of delivery. Using Nägele's rule, the nurse calculates the estimated date of delivery (EDD) as: 1. May 25, 2017 2. May 31, 2017 3. June 1, 2017 4. July 1, 2017

3. June 1, 2017 Rationale For Nägele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse subtracts 3 months from the first day of the last menstrual period, adds 7 days, and then adjusts the year as necessary. Subtracting 3 months from August 25, 2016, yields May 25, 2016. Adding 7 days yields June 1, 2016. Adding 1 year to June 1, 2016 brings the EDD to June 1, 2017.

A nurse calculates an infant's Apgar score 1 minute after birth and obtains a score of 8. Based on this finding, which action should the nurse take? 1. Notifying the infant's pediatrician 2. Administering oxygen to the infant 3. Recalculating the infant's Apgar score 5 minutes after birth 4. Attempting to stimulate the infant by rubbing the infant's back

3. Recalculating the infant's Apgar score 5 minutes after birth Rationale The nurse calculates the infant's Apgar score at 1 and 5 minutes after birth for rapid evaluation of early cardiopulmonary adaptation. If the score is between 8 and 10, no intervention is needed except for support of the infant's spontaneous efforts. If the score is between 4 and 7, the nurse gently stimulates the infant by rubbing his or her back and administers oxygen to the infant. A score between 0 and 3 indicates the need for resuscitation.

A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. 1. Perform the exercise while urinating. 2. Perform the exercise once only after urinating. 3. Repeat the contraction-relaxation cycle 30 times a day. 4. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. 5. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.

3. Repeat the contraction-relaxation cycle 30 times a day. 4. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. Rationale Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.

Janice comes to the clinic for her 39-week visit. (Refer to Janice's record by clicking "Chart" below.) Based on the data recorded (refer to medical record), the nurse concludes that one condition may be a problem. What is it? Blood pressure 162/110 mm Hg Temperature: 98.4° F Pulse 92 beats/min Respirations 14 breaths/min "I've had a headache for the last few days." "My vision seems blurry lately." "I've had to take off my rings because my fingers are swollen." Urine dipstick: proteinuria +2; glucose negative Bilateral ankle edema, +2 Edema of face and fingers Fundal height 38.5 cm Fetal heart tones (FHTs): 140 beats/min Deep tendon reflexes: 2+ 1. Eclampsia 2. Mild preeclampsia 3. Severe preeclampsia 4. Chronic hypertension

3. Severe preeclampsia Rationale A client experiencing severe preeclampsia will have a blood pressure of 160/110 mm Hg or higher on two separate occasions and will have 2+ to 3+ proteinuria on dipstick testing. Headaches, blurred vision, and facial and finger edema may also be present. Chronic hypertension would have been detected before pregnancy or before 20 weeks of gestation. Mild preeclampsia presents with a blood pressure of 140/90 mm Hg, minimal or no headache, no vision problems, and proteinuria of less than 2+ on dipstick testing. Eclampsia is an emergency that is characterized by seizure activity and sometimes coma.

Because maintaining a constant hormone level is important for effectiveness, the woman using oral contraceptive must take a pill at the same time each day. Unless a woman begins the pills during the first 7 days of the menstrual cycle, she should use another contraceptive method during the first week of the first cycle until blood hormone levels are established. If the woman misses a pill, she should take it as soon she remembers. If the woman misses a period and thinks that she might be pregnant, she should stop taking the pill and have a pregnancy test immediately. 1. She will need to have yearly liver function studies. 2. She will need to have a yearly cardiovascular test for 2 years and one every other year thereafter. 3. She will need to have a yearly pelvic and breast examination, Papanicolaou (Pap) smear, and blood pressure measurement. 4. She will need to have a pelvic and breast examination and Pap smear every 2 years, but her blood pressure should be checked every 6 months.

3. She will need to have a yearly pelvic and breast examination, Papanicolaou (Pap) smear, and blood pressure measurement. Rationale A woman who takes oral contraceptives should have a yearly pelvic and breast examination, Pap smear, and blood pressure measurement. Cardiovascular tests and liver function studies are not necessary.

During a conversation with a nurse, an older client states, "I'm so dissatisfied with my life — it's just been one disappointment after another." Using Erik Erikson's theory of psychosocial development, which interpretation of the client's statement does the nurse make? 1. The client has fulfilled his life's goals. 2. The client is looking back over his life and accepting what has occurred. 3. The client is demonstrating unsuccessful resolution of the crisis associated with this developmental stage. 4. The client is demonstrating successful resolution of the crisis associated with the developmental stage by verbalizing what has occurred during his life.

3. The client is demonstrating unsuccessful resolution of the crisis associated with this developmental stage. Rationale According to Erikson, all individuals pass through eight psychosocial stages over the course of a lifetime. Each stage represents a crisis in which the goal is to integrate physical, maturation, and psychosocial demands. In later adulthood, the psychosocial crisis is integrity versus despair. The task during this stage is to look back over one's life and accept its meaning. A sense of integrity and fulfillment indicates successful resolution of the crisis. Dissatisfaction with life indicates unsuccessful resolution of the crisis.

A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? 1. The procedure will take about 2 hours. 2. The obstetrician will locate the fetus with the use of the Leopold maneuvers. 3. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. 4. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.

3. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Rationale Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.

A nurse teaches the husband of a woman who is in the active phase of stage 1 labor how to perform effleurage on his wife. Which observation by the nurse indicates that the spouse is performing the procedure correctly? 1. The man lightly pushes on his wife's sacral area with his fist. 2. The man exerts steady pressure on his wife's abdomen during a contraction. 3. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. 4. The man exerts light pressure with the heel of the hand over the area of the uterine fundus.

3. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. Rationale Effleurage (light massage) and counterpressure are two methods that provide pain relief to a woman in the first stage of labor. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during a contraction. It is used to distract the woman from contraction pain. Counterpressure is steady pressure, applied to the sacral area with the fist or heel of the hand, that may help the woman cope with the sensations of internal pressure and pain in the lower back. Therefore the other options are incorrect.

A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? 1. She should cover the discoloration with makeup. 2. She should come to the clinic immediately to be checked. 3. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. 4. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen.

3. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. Rationale Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.

A nurse has just assisted in the delivery of a newborn infant and is preparing to help deliver the placenta. For which sign of placental separation does the nurse monitor the woman? 1. A soft, boggy fundus 2. Shortening of the umbilical cord 3. Vaginal fullness on examination 4. Assumption of a discoid shape by the uterus

3. Vaginal fullness on examination Rationale Signs of placental separation include a firmly contracting fundus; a change in the uterus from a discoid to a globular shape, which occurs as the placenta moves into the lower uterine segment; a sudden gush of dark blood from the introitus; apparent lengthening of the umbilical cord as the placenta descends to the introitus; the presence of vaginal fullness (placenta) on vaginal or rectal examination; and the presence of fetal membranes at the introitus.

After checking Penny again, the obstetrician decides to perform rupture of the membranes (ROM). Penny is told that she will need to empty her bladder first and then remain in bed after the procedure. Which of these assessment findings after ROM indicate that the amniotic fluid is normal? Select all that apply. 1. Strong odor 2. Thick and cloudy 3. Watery consistency 4. Greenish-brown color 5. Pale and straw colored

3. Watery consistency 5. Pale and straw colored Rationale Normal amniotic fluid is pale or straw-colored and of a watery consistency, without a strong odor. Thick, cloudy amniotic fluid or a strong odor might indicate an intrauterine infection. Greenish-brown fluid reflects the presence of meconium and may indicate that the fetus has had a hypoxic episode.

A nurse who has just assisted in the delivery of a newborn infant is providing initial care to the infant. Which action should the nurse take to prevent heat loss by way of conduction in the infant? 1. Keeping the infant away from drafty areas 2. Keeping the infant away from cold windows 3. Warming the hands before touching the infant 4. Drying the infant as soon as possible after birth

3. Warming the hands before touching the infant Rationale Conduction of heat away from the body occurs when a newborn comes in direct contact with an object that is cooler than his or her skin. Placing an infant on a cold surface or touching the newborn with cold hands or a cold stethoscope causes this type of heat loss. Convective heat loss occurs when heat is transferred to air surrounding the infant. Keeping the infant out of drafts and maintaining warm environmental temperatures help prevent this type of heat loss. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. An infant placed near a cold window loses heat by way of radiation. Heat loss by way of evaporation occurs when a wet surface is exposed to air. Drying the infant as soon as possible after birth and after bathing prevents this type of heat loss.

The nurse developing a plan of care for Mrs. Valenti will prioritize the following concerns from the highest priority (1) to the lowest (2) 1. Potentially damaged skin 2. Possible injury 3. Loss of fluid volume 4. Confusion

3. Loss of fluid volume 4. Confusion 1. Potentially damaged skin 2. Possible injury Rationale The most appropriate (highest priority) concern for the client i=who is dehydrated is loss of fluid volume, Possible injury and confusion complete for second priority. Because confusion is an actual client problem and could place client at risk for an injury, confusion is the second priority and possible injury is the third priority. The possibility of damaged skin is the fourth priority.

During the 30-week follow-up visit, the nurse assesses Janice and asks, "How are you feeling these days?" Which of these statements from Janice would indicate that further assessment is needed? Select all that apply. 1. "I spend so much time going to the bathroom!" 2. "I haven't been sleeping well for several days." 3. "I've noticed that I get out of breath after I vacuum the floors." 4. "Since yesterday I've noticed that the baby isn't moving as much." 5. "I've noticed that my fingers and face have been swollen when I wake up in the morning."

4. "Since yesterday I've noticed that the baby isn't moving as much." 5. "I've noticed that my fingers and face have been swollen when I wake up in the morning." Rationale During the second and third trimesters of pregnancy, certain signs and symptoms may indicate complications. Any change in the pattern or frequency of fetal movements should be investigated immediately to detect or rule out fetal jeopardy. Swelling of the face or fingers may indicate a hypertensive condition or preeclampsia. Discomforts that are expected during this trimester of pregnancy include insomnia, frequent urination (caused by impingement of the enlarging uterus on the bladder, resulting in reduced bladder capacity), and shortness of breath (resulting from limitation of diaphragm movement by the enlarging uterus).

Three months later, Marilyn visits the health care provider's office because of ear pain. The health care provider's assessment and prescription are shown in Marilyn's health record (click "Chart" below). Based on these prescriptions, what should the nurse teach Marilyn at this time? 1. The vitamins should not be taken while Marilyn is taking the antibiotic. 2. The oral contraceptive should be stopped until the antibiotic prescription is finished. 3. The oral contraception should be stopped while Marilyn is taking the pseudoephedrine for nasal congestion. 4. An alternate form of birth control will be needed while Marilyn is taking the ampicillin and for at least 1 month afterward.

4. An alternate form of birth control will be needed while Marilyn is taking the ampicillin and for at least 1 month afterward. Rationale Several medications, including penicillin antibiotics, can reduce the effectiveness of oral contraceptives, which may in turn result in unintended pregnancy. Marilyn should use an alternate form of birth control while taking the ampicillin and for at least 1 month afterward, but the oral contraceptive should not be stopped. Vitamins and pseudoephedrine do not interact with oral contraceptives.

That evening, during an assessment, the nurse finds that Annie's uterine fundus is above the umbilicus and to the left of the midline of the abdomen. What action by the nurse is a priority? 1. Performing fundal massage 2. Performing a sterile urinary catheterization 3. Assessing the lochia on Annie's perineal pad 4. Assisting Annie to the bathroom to help her void

4. Assisting Annie to the bathroom to help her void Rationale A full bladder causes the uterus to be displaced above the level of the umbilicus and off to one side of the midline of the abdomen. It may also lead to uterine atony, because it prevents the uterus from contracting normally. The priority nursing intervention is to assist the woman in emptying her bladder as soon as possible, either by taking her to the bathroom or offering a bedpan if she is not ambulatory. Fundal massage should be performed, if the fundus is boggy, once the bladder has been emptied. Catheterization is done only if the woman is unable to void after measures have been taken to encourage urination. Assessing the lochia does not address the problem.

A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? 1. Checking the woman's blood pressure 2. Calling the obstetrician to the examining room 3. Placing a cool cloth on the woman's forehead 4. Assisting the client into a lateral recumbent position

4. Assisting the client into a lateral recumbent position Rationale When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.

Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? 1. The result of the Rh factor screen is normal. 2. Because the Rh factor is not present, no additional testing is necessary. 3. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. 4. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.

4. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation. Rationale If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.

A nurse prepares to teach a pregnant woman to perform tailor-sitting exercises. Which instruction should the nurse provide to the client? 1. Lie flat on the back and place both feet against a wall. 2. Position self on the hands and knees and arch the back five times in a 30-second period. 3. Sit with the legs straight, press the knees toward the floor, and hold the position for 10 seconds. 4. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes

4. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes Rationale Tailor-sitting exercises are useful in alleviating heartburn and shortness of breath or dyspnea. The woman sits on the floor, bends her knees, places the soles together, uses her thigh muscles to press the knees to the floor, and holds the position for 5 to 15 minutes. The other options are incorrect descriptions of this exercise.

A subarachnoid (spinal) block is administered to a woman before a cesarean section. During the immediate postpartum period, which vital sign does the nurse check most closely as part of monitoring for adverse effects of the block? 1. Temperature 2. Apical pulse 3. Respirations 4. Blood pressure

4. Blood pressure Rationale The injection site for a subarachnoid block is in the spinal subarachnoid space at L3-L5. This type of anesthesia, administered just before birth, relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities. The adverse effects of a subarachnoid block are maternal hypotension, bladder distention, and postdural puncture headache. Although the nurse would monitor the woman's temperature, pulse, and respirations, the blood pressure must be monitored most closely.

A woman who has just delivered a baby asks the nurse when she may resume sexual intercourse. Which response should the nurse give to the client? 1. Intercourse may be resumed at any time after delivery. 2. Intercourse may not be resumed until menstruation returns. 3. Intercourse may not be resumed until after the 6-week checkup with the obstetrician. 4. Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed

4. Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed Rationale The woman who has just given birth should be told that she may safely resume sexual intercourse by the second to fourth week after delivery, when bleeding has stopped and the episiotomy has healed. The other options are incorrect.

Penny's labor is progressing slowly because her contractions are inadequate, so the obstetrician prescribes intravenous oxytocin to augment labor. While the oxytocin is being administered, the nurse, monitoring Penny closely, notes that her contractions are occurring every 3 minutes and are lasting 60 seconds. Which action should the nurse take? 1. Contact the obstetrician 2. Stop the oxytocin infusion 3. Transport Penny to the delivery room 4. Maintain the current dosage of oxytocin

4. Maintain the current dosage of oxytocin Rationale Oxytocin, a hormone naturally produced by the posterior pituitary gland, stimulates uterine contractions and may be used to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions. The nurse monitors the client closely and maintains the dosage if the intensity of contractions results in intrauterine pressure of 40 to 90 mm Hg (as shown by an internal monitor), if the duration of contractions is 40 to 90 seconds, if the contractions come at 2- to 3-minute intervals, or if cervical dilation of 1 cm/hr occurs in the active stage. Oxytocin is stopped if uterine hyperstimulation or a nonreassuring pattern of fetal heart rate occurs. There is no need to contact the obstetrician at this time or to transport Penny to the delivery room, because she is still progressing through the first stage of labor.

A pregnant woman expresses concern to the nurse about how her 10-year-old daughter will adapt to a newborn's introduction into the home. Which response should the nurse make to the woman? 1. Most children resent a "newcomer" to the home. 2. An only child always has difficulty when a new baby arrives. 3. She must provide a great deal of attention to the 10-year-old to help prevent resentment on the older child's part. 4. Older school-age children often enjoy taking responsibility for the care of a younger sibling.

4. Older school-age children often enjoy taking responsibility for the care of a younger sibling. Rationale Older school-age children often enjoy taking responsibility for the care of a younger sibling. The nurse would appropriately teach the pregnant woman measures to deal with adaptation to a new infant. The information in the other options is inaccurate.

Which precautions should the nurse take to prevent newborn abduction? Select all that apply. 1. Placing the newborn's crib close to the mother's door 2. Instructing the mother to carry the newborn to the nursery after feeding 3. Closing the hospital room door if the infant needs to be left unattended 4. Questioning unknown person(s) who are carrying large bags or packages 5. Ensuring that all health care personnel wear proper name (identification) badges

4. Questioning unknown person(s) who are carrying large bags or packages 5. Ensuring that all health care personnel wear proper name (identification) badges Rationale Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking a nurse to attend to the newborn if no one is available to watch the newborn (the newborn is never left unattended). The nurse should monitor the environment closely and question any suspicious or unknown person, especially one carrying a large bag or package that could contain an infant.

The nurse notes documentation in the record of a client in labor that the client is completely effaced. Based on this information, what conclusion should the nurse make? 1. The cervical os is completely dilated. 2. The client will require induction with the use of oxytocin. 3. Enlargement of the cervical canal that occurs during the first stage of labor is complete. 4. The shortening and thinning of the cervix that occurs during the first stage of labor is complete.

4. The shortening and thinning of the cervix that occurs during the first stage of labor is complete. Rationale Effacement is the shortening and thinning of the cervix that occurs during the first stage of labor. Dilation is the enlargement of cervical os and cervical canal during the first stage. When the cervical os is completely dilated, the client is prepared for the birth of the baby. Induction is the deliberate initiation of uterine contractions that stimulates labor. In this situation, induction is not necessary.

Once the nurse has implemented treatment for Mrs. Valenti's dehydration, which ocurrence indicates the best expected outcome should the nurse be alert for?1. Thirst 2. Dry mucous membranes 3. Decrease in blood pressure 4. Urine output greater than 30 mL/hr

4. Urine output greater than 30 mL/hr Rationale The expected outcome for the client with deficient fluid volume is that adequate fluid volume and electrolyte balance will return, as evidenced by a urine output greater than 30 mL/hr, normal blood pressure, decreasing heart rate, consistent weight, and normal skin turgor. Thirst, dry mucous membranes, and a decrease in blood pressure are defining characteristics of deficient fluid volume.

One hour after delivery, the nurse checks Annie for postpartum bleeding. Which procedure is best for this purpose? 1. Assessing Annie's blood pressure 2. Visually assessing bleeding by checking Annie's perineal pad 3. Asking Annie how much bleeding she has had since the last check 4. Visually assessing bleeding by checking the linens under Annie's buttocks and the perineal pad

4. Visually assessing bleeding by checking the linens under Annie's buttocks and the perineal pad Rationale Estimating blood loss after delivery is important and can be done by visually examining the perineal pad. However, when the mother is supine, blood may flow between the buttocks and onto the linens beneath the mother, not onto the perineal pad. Therefore, it is also important to check the linens under the mother's buttocks for bleeding. The blood pressure may not change unless a significant amount of bleeding occurs. Asking Annie about the amount of bleeding is not a reliable means of assessment. Checking the bed linens and perineal pad provides a complete assessment of blood loss.

A nurse is performing an ophthalmoscopic examination of an older client. Which age-related change would the nurse expect to note while viewing the retina? 1. Clear fundus 2. Red blood vessels 3. Yellow-orange optic disc 4. Yellow spots near the macula

4. Yellow spots near the macula Rationale Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula. Red blood vessels, a clear fundus, and a yellow-orange optic disc are all normal findings, not age-related changes.

A nurse in a daycare center is planning play activities for a group of toddlers. which choice are the Most appropriate play material for these children? 1. Videos, compact disc player, board games. 2. Rattles, stuffed animals, sneaky dolls, soft mobiles. 3. Cards, Monopoly games, sewing kits, paints by number kits 4. Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper

4. Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper Rationale: The toddler engages in parallel play. Appropriate toys promote increased locomotive skills, meet the need for tactile play, and are safe. Blocks, a rocking horse, finger paints, wooden puzzles, thick crayons, and paper are all appropriate toys for a toddler. Videos, a compact disc player, board games, sewing kits, and paint-by-number kits are more appropriate for a school-age child. Rattles, stuffed animals, squeaky dolls, and soft mobiles are more appropriate for an infant.

A nurse has provided information to a 16-year-old girl about adequate nutritional intake. Which statement by the girl indicates a need for additional information? 1. It is all right to eat pizza for breakfast once in awhile 2. It is important to eat at least two servings of fruit per day. 3. it is acceptable to eat an occasional hamburger and fries at a fast food restaurant 4. It is acceptable to replace the daily milk requirement with a protein food such as a cheeseburger

4. It is acceptable to replace the daily milk requirement with a protein food such as a cheeseburger Rationale According to the MyPlate food plan, three servings per day should be consumed from the dairy group. Protein foods are not acceptable substitutes for this food group. The other statements are accurate.

During the office visit, the nurse assesses Joel's development level, document the findings, and review the data. -Physical development: Chest circumference exceeding head circumference, Lateral diameter of chest exceeding anteroposterior diameter, has 16 primary teeth -Language development: Use pronouns "I","me","you", Refers to self by name, Talks incessantly, Understands directional commands -Socialization Development: Does not tolerate separation from parents, fears strangers, brief attention span, willing to share toys. Which statement correctly describes the nurse's assessment of these findings? 1. All findings are appropriate for a 2-year-old child 2.The physical findings are not appropriate for a 2-year-old child 3. The language findings are not appropriate for a 2-year-old child 4. The socialization findings are not appropriate for a 2-year-old child

4. The socialization findings are not appropriate for a 2-year-old child Rationale By the age of 2 years, children should have a sustained attention span, exhibit increased independence from their parents, be less likely to fear strangers, and have an awareness of ownership, as expressed by phrases such as "my toy." The findings listed under the "Physical Development" and "Language Development" tabs are appropriate for Joel's age.

Joanna Burns has brought her 2-year-old son, Joel, to the well-baby clinic for a scheduled visit. She expresses concern to the nurse about her son's behavior, telling the nurse that she has a great deal of difficulty getting Joel to bed at night. Joel throws temper tantrums to postpone the event, she reports. Joanna also tells the nurse that because of this behavior she is worried about being able to toilet-train Joel. Joanna asks the nurse about strategies to deal with Joel's behavior.

Answer the following questions

Marilyn Formosa, 27 years old, schedules an appointment at the family planning clinic. Marilyn tells the nurse that she will be getting married in 1 month, that she is seeking a convenient form of contraception, and that she would like to take the pill. She tells the nurse that her relationship with her fiancé has been mutually monogamous since she started seeing him, 8 years ago. Marilyn says that she and her fiancé plan to have children at some point.

Answer the following questions

Mrs. Frances Valenti, 85 years old, lives in a residential home for older adults. She visits the clinic and tells the nurse that she is having persistent diarrhea. During the physical assessment, the nurse notes that Mrs. Valenti appears weak when walking, that she is intermittently confused, and that her skin is dry. Her temperature is 101° F; 38.3°C, her apical pulse is 92 beats/min and irregular, her respiratory rate is 28 breaths/min, and her blood pressure is 108/70 mm Hg. Mrs. Valenti tells the nurse that she has been able to eat and drink small amounts but that the diarrhea will not stop. The nurse suspects that Mrs. Valenti is dehydrated.

Answer the following questions

A nurse is planning to determine the presentation and position of the fetus, using the Leopold maneuver. Prioritize and number the nursing action in order in which they are performed. (The number 1 would indicate the first and the number 6 represents the last action) Ask the woman to empty her bladder Palpate the side of her uterus to determine the location of the fetal back Wash hands and don gloves Palpate the uterine fundus to determine the fetal part felt Palpate the suprapublic area determine whether the presenting part is engaged Explain the procedure to the woman

Explain the procedure to the woman Ask the woman to empty her bladder Wash hands and don gloves Palpate the uterine fundus to determine the fetal part felt Palpate the side of her uterus to determine the location of the fetal back Palpate the suprapublic area determine whether the presenting part is engaged

Priority points to remember! (Infants, Child, Adolescents)

Human milk is the best food for infants. skim and low-fat milk should not be used for infants because the essential fatty acids are inadequate and the solute concentration of protein and electrolyte is too high Fluoride supplementation may be needed starting around 6 months of age, depending on the infants intake of fluoridated tap water Introduce solids foods one at a time,usually at intervals of 4 to 7 days, to identify food allergies. Avoid giving solid foods that place the child at risk for chocking, such as nuts,food with seeds, raisins, popcorn, grapes, and pieces of hot dog Baby-proof the home; hazards items must be stored out of reach Toddlers are eager to explore the world around them Preschoolers are active and inquisitive;because of their magical thinking, they may believe that the daring feats seen in cartoons are possible and may attempt them Children should always wear a helmet when riding a bike,using inline skates or skateboards,or participating in other activities that may result in falls Teach children to avoid speaking to strangers and to never accept rides,toys,or gifts from strangers Teach children how to call 911 in an emergency situation Teach parents to keep the poison-control hotline number available Adolescents are risk takers Discuss such issues as bullying, date rape, sexual relationships, and sexually transmitted infections and the dangers of the Internet with regards to communication and setting up meetings (dates) with unknown person.

A nurse is providing information to the parents of a 5-month-old about introducing sold foods to the infant. Which of the following instructions should the nurse give to the parents? 1. Cheese should not be used a substitute for meat. 2. Introduce one new food at a time at intervals of 4 to 7 days. 3. Mix soft solid food with formula if the infants refuses to eat. 4. Start with fruits and vegetables; if these are tolerated, add cereal to the diet.

Introduce one new food at a time at intervals of 4 to 7 days. Rationale: Solids may be added to feedings when the infant is 5 to 6 months old. Rice cereal is introduced first because of its low allergenic potential. The recommended sequence after the introduction of rice is weekly introduction of fruits, followed by vegetables and then meat. Cheese may be used as a substitute for meat or as a finger food. Parents are instructed to introduce one food at a time, usually at intervals of 4 to 7 days, as a means of identifying food allergies. Foods are never mixed with formula in the bottle