411 final exam

The child has been diagnosed with severe dehydration. The health care provider has prescribed a bolus of 20 ml/kg of normal saline over a 2-hour period. The child weighs 63.5 lb (28.8 kg). At which ml/hour should the nurse set the child's intravenous administration pump? Record your answer using a whole number.

288 Using the child's weight in kilograms, multiply by prescribed dose. 28.8 kg x 20 ml/kg = 576 ml. Divide by time administered. 576 ml ÷ 2 hr = 288 ml/hr

In which woman would the nurse most likely expect to find fibrocystic breast changes? A) 35-year-old B) 15-year-old C) 25-year-old D) 55-year-old

A) 35-year-old Fibrocystic breast changes are most common in women between the ages of 30 and 50 years. The condition is rare in postmenopausal women not taking hormone replacement therapy.

An ultrasound of a fetus' heart shows that "normal fetal circulation is occurring." Which of the following statements is consistent with the finding? A) A right-to-left shunt is seen between the atria. B) Blood is returning to the placenta via the umbilical vein. C) Blood is returning to the right atrium from the pulmonary system. D) A right-to-left shunt is seen between the umbilical arteries

A) A right-to-left shunt is seen between the atria. This is correct. The foramen ovale is a duct between the atria. In fetal circulation, there is a right-to-left shunt through the duct. Blood returns to the placenta via the umbilical arteries. Most of the blood bypasses the pulmonary system. The blood that does enter the pulmonary system returns to the left atrium. There is no duct between the umbilical arteries.

A 36-week-gestation client is being seen in the prenatal clinic. Where would the nurse expect the fundal height to be felt? A) At the xiphoid process B) At a point between the umbilicus and the xyphoid C) At the umbilicus D) At a level directly above the symphysis pubis

A) At the xiphoid process At 36 weeks' gestation, the fundus should be felt at the xiphoid process. Between 21-35 weeks gestation, the fundus should be felt between umbilicus and xyphoid c. At 20 weeks' gestation, the fundus should be felt at the umbilicus. d. At 12 weeks' gestation, the fundus should be felt directly above the symphysis pubis.

The nurse is taking a health history of a 2-year-old girl presenting with a sudden onset of severe vomiting. Which description would suggest an obstruction? A) Bilious vomiting B) Projectile vomiting C) Effortless vomiting D) Bloody vomiting

A) Bilious vomiting The contents and character of the vomitus may give clues to the cause of vomiting. Bilious vomiting is never considered normal and suggests an obstruction. Projectile vomiting is associated with pyloric stenosis. The gender and the age of the child are not consistent with pyloric stenosis. Effortless vomiting is often seen in gastroesophageal reflux. Bloody emesis can signify esophageal or gastrointestinal bleeding.

The nurse is interviewing a gravid client during the first prenatal visit. The client confides to the nurse that she owns a number of pet animals. The nurse should advise the client to be especially careful to refrain from coming in contact with the stools of which of the pets? A) Cat B) Dog C) Hamster D) Bird

A) Cat The client should refrain from coming in direct contact with cat feces. Cats often harbor toxoplasmosis, a teratogenic illness. No pathology has been associated with the feces of pet dogs, hamsters, or birds

The nurse is developing a teaching plan for the parents of an 11-month-old infant with gastroesophageal reflux disease (GERD). The child will be managed medically. What actions would the nurse incorporate into the teaching plan? Select all that apply. A) Giving the child small frequent feedings B) Burping the infant at the end of the feeding C) Thinning the formula with water to ease flow D) Keeping the child upright for 30 minutes after feeding

A) Giving the child small frequent feedings D) Keeping the child upright for 30 minutes after feeding

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? A) Glucose B) Protein C) brown fat D) carbohydrate

A) Glucose Rationale: Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours

The nurse is assessing a newly admitted 14-year-old and notes that he makes very little eye contact, becomes very frustrated with questions and conversation, and does not smile or laugh. What nursing diagnoses will the nurse add to the care plan based on these assessment findings? Select all that apply. A) Impaired social interaction B) Delayed growth and development C) Ineffective individual coping D) Disturbed thought process E) Imbalanced nutrition, less than body requirements

A) Impaired social interaction C) Ineffective individual coping Limited eye contact lack of smiling support the nursing diagnosis of Impaired social interaction. Becoming frustrated easily with conversation supports both Impaired social interaction and Ineffective individual coping.

A nurse is assisting with the gestational age assessment of a newborn. When assessing the newborn's physical maturity, which areas would the nurse likely address? Select all that apply. A) Lanugo B) Breast tissue C) Posture D) Arm recoil E) Square window

A) Lanugo B) Breast tissue Answer a,b Rationale: Gestational Age Assessment(physical maturity) Skin Lanugo Plantar surface Breast tissue Eye-ear Genitals (male/female)

The nurse is providing health teaching to a group of gravid women. One woman states that she is a smoker and asks about the impact of smoking on her pregnancy. The nurse responds that which of the following fetal complications may develop? A) Low neonatal birth weight B) Excess pregnancy weight gain C) Severe neonatal anemia D) Maternal hyperbilirubinemia

A) Low neonatal birth weight Low neonatal birth weight is the most common complication seen in pregnancies complicated by cigarette smoking. Excess pregnancy weight gain is not associated with pregnancies complicated by cigarette smoking. Severe neonatal anemia is not associated with pregnancies complicated by cigarette smoking. Maternal hyperbilirubinemia is not associated with pregnancies complicated by cigarette smoking.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. A) Nasal flaring B) Respiratory rate of 75 breaths per minute C) Bluish coloration of hands and feet D) Chest retractions E) Heart rate of 120 beats per minute

A) Nasal flaring B) Respiratory rate of 75 breaths per minute D) Chest retractions Answer a, b, d Rationale: Signs of Respiratory Distress Cyanosis Tachypnea Expiratory grunting Sternal retractions Nasal flaring

A school-aged child is brought to the emergency room with severe abdominal pain. The nurse performs a physical assessment. Which assessment parameters indicate appendicitis? Select all that apply. A) Normal to hyperactive bowel sounds early B) Hypoactive bowel sounds with perforation C) Irritation and pain in the right lower quadrant D) Rebound tenderness present with palpation in the left upper quadrant E) Distended abdomen with unperforated appendicitis F) Low-grade fever, nausea, anorexia, and vomiting

A) Normal to hyperactive bowel sounds early B) Hypoactive bowel sounds with perforation C) Irritation and pain in the right lower quadrant F) Low-grade fever, nausea, anorexia, and vomiting On auscultation, bowel sounds are normal to hyperactive early in the course of appendicitis but become hypoactive with perforation. Percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness is present with palpation in the right lower quadrant. Low-grade fever, nausea, anorexia, and vomiting typically occur after the onset of abdominal pain. The abdomen appears flat with unperforated appendicitis, but abdominal distention may be present once perforation occurs.

A nurse is collecting data from a client tot identify risk factors associated with HIV. Which of the following are risk factors with increased risk of HIV? SATA A) Perinatal exposure B) Pregnancy C) Having a monogamous partner D) Being an older woman E) Occupational exposure

A) Perinatal exposure D) Being an older woman E) Occupational exposure Rationale: perinatal exposure is a RF associated with HIV. Clients who are pregnant should take precautionary measures to prevent perinatal infection as a neonate. Exposures that lead to mucosal disruption and bleeding are associated with the highest risk of infection. Being an older adult woman is a risk factor for HIV due to vaginal dryness and thinning of the vaginal wall. Occupational exposure, such as a health care provider, is a risk factor associated with HIV. Practice connection: The risk of perinatal exposure to HIV can be reduced by maternal antiviral therapy. Factors that increase risk of exposure through occupational exposure include deep injury with a contaminated device.

The nurse is caring for a child with epididymitis. When planning care, which intervention may be included? A) Scrotal elevation B) Warm compresses C) Corticosteroid therapy D) Catheterization

A) Scrotal elevation Epididymitis is caused by a bacterial infection. Treatment may include scrotal elevation, bed rest, and ice packs to the scrotum. Pharmacotherapy may include antibiotics, pain medications, and nonsteroidal anti-inflammatory drugs (NSAIDs). Warm compresses would result in vasodilation and do little to relieve the pain and swelling of the condition. Corticosteroid therapy is not included in the plan of care for the condition. Voiding is not impacted by epididymitis. Catheterization is not indicated.

The nurse is caring for a primigravida who asks for advice on foods that are high in vitamin C because, she says, "I hate oranges." The nurse states that 1 cup of which of the following raw foods will meet the client's daily vitamin C needs? A) Strawberries B) Asparagus C) Iceberg lettuce D) Cucumber

A) Strawberries Strawberries are an excellent source of vitamin C. Although asparagus has some vitamin C, it is not an excellent source. Iceberg lettuce is a poor source of vitamin C. Cucumber is a poor source of vitamin C.

A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid consuming during her pregnancy? A) Uncooked brie cheese B) Fresh bartlett pears C) Baked sweet potatoes D) Grilled lamb shank

A) Uncooked brie cheese Soft cheese may harbor Listeria. The client should avoid consuming uncooked soft cheese. Once it has been washed, a fresh pear is a nutritious food for a pregnant woman to consume. Sweet potatoes, prepared by any method, are very nutritious for a pregnant woman to consume. Grilled lamb is a nutritious food for a pregnant woman to consume, although it should be well cooked.

During the newborn examination, the nurse would suspect spina bifida occulta if what finding is present? Select all that apply. A) a dimpling at the base of spine B) abnormal tufts of hair at the base of spine C) discolored skin at the base of spine D) head circumference above the 90th percentile E) continuous dribbling of urine

A) a dimpling at the base of spine B) abnormal tufts of hair at the base of spine C) discolored skin at the base of spine Answer a,b,c Rationale: The defect is usually in the lumbar sacral area. Signs and symptoms include: Dimpling at the base of the spine Abnormal patches of hair, Discoloring of the skin at the defect

The nurse is teaching women in a community clinic about urinary incontinence. The nurse knows that women who have weak pelvic floor muscles may have stress incontinence. Which intervention would be least effective in relieving urinary incontinence? A) decreasing oral intake of fluids to less than 1 L/day B) performing Kegel exercises C) performing urination every 2 hours D) participating in a smoking support group

A) decreasing oral intake of fluids to less than 1 L/day The least effective intervention would be to decrease fluids to less than 1.5 L/day. This could put the woman at risk for dehydration and urinary infection. All other choices are effective in managing urinary incontinence.

A nurse is assessing a woman who has come to the clinic reporting heavy menses. The nurse suspects that that the client may have a uterine fibroid based on which findings? Select all that apply. A) feeling of fullness in the lower pelvis B) urine retention C) pain during sexual intercourse D) upper back pain E) pain accompanying menstruation

A) feeling of fullness in the lower pelvis C) pain during sexual intercourse (dyspareunia) E) pain accompanying menstruation (dysmenorrhea) A woman's symptoms can include heavy or painful menses, feeling "full" in the lower pelvis, urinating frequently, pain during sexual relations, lower back pain, and infertility.

A neonate is being admitted to the observational nursery with the diagnosis of postmaturity. What would the nurse expect to find with this gestational age variation? Select all that apply. A) meconium-stained skin and fingernails B) abundant lanugo C) decreased breast tissue D) thin umbilical cord E) peeling, wrinkled skin F) abundant vernix caseosa G) few sole creases

A) meconium-stained skin and fingernails D) thin umbilical cord E) peeling, wrinkled skin Answer A, D, E Rationale: Post-term newborns typically exhibit the following characteristics: Dry, cracked peeling wrinkled skin Vernix caseosa and lanugo are absent Long, thin extremities Creases that cover the entire soles of the feet Wide-eyed, alert expression Abundant hair on scalp Thin umbilical cord Long fingernails Limited vernix and lanugo Meconium-stained skin and fingernails

A nurse is screening a client for intimate partner violence during a health care visit. Which finding would lead the nurse to suspect that the client may be a victim? Select all that apply. A) reference to a friend who is being abused B) evasive answers to questions asked C) reported injury consistent with current findings D) display of anger toward health care providers E) overprotectiveness of partner

A) reference to a friend who is being abused B) evasive answers to questions asked D) display of anger toward health care providers E) overprotectiveness of partner Clues to possible intimate partner violence include: referring to abuse of a "friend"; answering questions evasively; reporting injuries that are inconsistent with the findings; displaying anger toward health care providers; and the partner being overprotective at a visit.

The nurse prepares a client for a total abdominal hysterectomy with bilateral salpingo-oophorectomy due to endometrial cancer. The nurse observes that the client is talking continuously and has difficulty maintaining eye-contact. Which response by the nurse is best? A. "What are your concerns about the surgery?" B. "Why isn't your husband here with you?" C. "Are you afraid that you are going to die?" D. "You seem to be coping with the surgery very well."

A. "What are your concerns about the surgery?" Rationale: A. Correct answer-client's behavior indicated that she feeling anxious. Allow the client to verbalize her feelings. Post-op assess for hemorrhage, infection, and thrombophlebitis. B. Judgement. Avoid why questions C. Yes/no questions are not therapeutic; client's behavior indicates anxiety D. Signs of anxiety include: restlessness, pacing, poor eye contact, glancing around, repeating things over and over, and fidgeting.

The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis? A. A woman with diabetes, vaginal birth, HR 110, temperature 101.7° F (38.7° C) on the third postpartum day. The next day, appears ill; temperature now 102.9° F (39.3° C); WBC 31,500 cells/mm; and negative blood cultures. B. A woman with a history of infection and smoking, temperature 101° F (38.3° C) on the fourth postpartum day; reports severe perineal pain; edges of the episiotomy have separated. C. An obese woman with temperature 100.4° F (38° C) at 12 hours after birth; lochia is moderate; negative vaginal cultures. D. A woman with PROM before birth; reports severe burning with urination, malaise and severe temperature spikes on the 7th postpartum day. WBC is 21,850 cells/mm&$176;3; temperature 101° F (38.3° C); skin pale and clammy.

A. A woman with diabetes, vaginal birth, HR 110, temperature 101.7° F (38.7° C) on the third postpartum day. The next day, appears ill; temperature now 102.9° F (39.3° C); WBC 31,500 cells/mm; and negative blood cultures. Answer A- Signs and symptoms of endometritis include lower abdominal tenderness or pain on one or both sides Temperature elevation (>38º C) Foul-smelling lochia, anorexia, nausea, fatigue and lethargy. Leukocytosis and elevated sedimentation rate. Diabetes including gestational diabetes (decreases body's healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth). See Box 22.1 Factors placing Women at Risk for Postpartum infections.

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply. A. Has the mother ever been sensitized to Rh-positive blood? B. What was the birth weight of the infant? C. Has the mother had any previous pregnancies? D. Has she delivered by cesarean section or vaginally? E. Has the mother experienced any miscarriages or abortions?

A. Has the mother ever been sensitized to Rh-positive blood? C. Has the mother had any previous pregnancies? E. Has the mother experienced any miscarriages or abortions? Correct answer A,C, E Rationale -If the client is Rh-negative, check the Rh status of the newborn. Verify that the woman is Rh-negative and has not been sensitized, that her indirect Coombs test (antibody screen) is negative, and that the newborn is Rh-positive. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process. Rh incompatibility most commonly arises with exposure of an Rh-negative mother to Rh-positive fetal blood during pregnancy or birth, during which time erythrocytes from the fetal circulation leak into the maternal circulation. Isoimmunization can also occur during an amniocentesis, ectopic pregnancy, placenta previa, placenta abruption, in utero fetal death, spontaneous abortion, or abdominal/pelvic trauma. The current recommendation is for every Rh-negative nonimmunized woman to receive RhoGAM at some point between 28 and 32 weeks' gestation and again within 72 hours after giving birth. Other indications for RhoGAM include: Ectopic pregnancy Chorionic villus sampling Amniocentesis Prenatal hemorrhage Molar pregnancy Maternal trauma Percutaneous umbilical sampling Therapeutic or spontaneous abortion Fetal death Fetal surgery

A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply. A. Hormonal changes B. Fatigue C. Lack of activity D. Discomfort E. Disrupted sleep patterns

A. Hormonal changes B. Fatigue D. Discomfort E. Disrupted sleep patterns Correct answer A, B, D, E Rationale-the woman experiences rapid cycling mood symptoms during the first postpartum week typically. The woman exhibits mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, despondency, feelings of being overwhelmed, difficulty thinking clearly, and fatigue (Pop et al., 2015). Emotional lability is the most prominent symptom of the maternity blues. The "blues" typically peak on postpartum days 4 and 5 and usually resolve by postpartum day 10. Biologic, psychological, and social factors have been hypothesized as relevant to blues causation, but no studies have validated this. Although the woman's symptoms may be distressing, they do not reflect psychopathology and usually do not affect the mother's ability to function and care for her infant. Baby blues are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience, as well as assistance in caring for herself and the newborn. However, follow-up of women with postpartum blues is important because up to 20% go on to develop postpartum depression Lack of activity is associated with postpartum depression. As well as Restless Worthless Guilty Hopeless Moody Sad Overwhelmed Loss of enjoyment Low energy level Loss of libido

A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Select all that Apply. A. Labor of 1 1/2 hours B. Labor induction with oxytocin C. Forceps or vacuum birth D. Third stage of labor of 10 minutes E. Hemoglobin 10.0 g/dL (100.0 g/L)

A. Labor of 1 1/2 hours B. Labor induction with oxytocin C. Forceps or vacuum birth A, B, C-Rationale- Risk Factors for Postpartum hemorrhage Precipitous labor (less than 3 hours) Uterine atony Placenta previa or abruptio placenta Labor induction or augmentation Operative procedures (vacuum extraction, forceps, cesarean birth) Retained placental fragments Prolonged third stage of labor (more than 30 minutes) Multiparity, more than three births closely spaced Uterine overdistention (large infant, twins, hydramnios)

A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period? A. She sits and rocks her infant for long intervals. B. She is eager to talk about her birth experience. C. She has not asked for anything for pain all day. D. She did her perineal care independently.

A. She sits and rocks her infant for long intervals. Correct Answer A: the second phase of maternal adaptation, is characterized by dependent and independent maternal behavior. This phase typically starts on the second to third day postpartum and may last several weeks. As the client regains control over her bodily functions during the next few days, she will be taking hold and becoming preoccupied with the present. She will be particularly concerned about her health, the infant's condition, and her ability to care for her or him. She demonstrates increased autonomy and mastery of her own body's functioning, and a desire to take charge with support and help from others. She will show independence by caring for herself and learning to care for her newborn, but she still requires assurance that she is doing well as a mother. She expresses a strong interest in caring for the infant by herself. B. This answer is part of the "taking- in phase" C and D. does not have to do with the "taking-hold phase."

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply. A. Walk alongside the client to the bathroom. B. Check her blood pressure after she stands up. C. Elevate the head of the bed for several minutes before getting her up. D. Sit her in a chair after getting out of bed before going to the bathroom. E. Frequently ask the client how her head feels.

A. Walk alongside the client to the bathroom. C. Elevate the head of the bed for several minutes before getting her up. E. Frequently ask the client how her head feels. A, C, E- Rationale-Be alert for orthostatic hypotension, which can occur when the woman moves rapidly from a lying or sitting position to a standing one.

Mom of adolescent diagnosed w/ T1 diabetes sports

Add extra snack

Fell from swing, assess airway and then what

Assess LOC

The nurse is assessing a toddler and palpates a sausage-shaped mass in the upper mid abdomen. When taking the toddler's history, what question would the nurse ask the parent first? A) "Can you describe any pain your toddler is having?" B) "Has your toddler been having different colored stools?" C) "How is your toddler's appetite?" D) "Has your toddler been around anyone who has been sick?"

B) "Has your toddler been having different colored stools?" A sausage-shaped mass in the upper mid abdomen is a classic sign of intussusception. Intussusception occurs when the proximal segment of the bowel "telescopes" into a more distal segment of the bowel, thus the sausage-shaped mass. Another classic sign of intussusception is stools that appear like currant jelly. These are stools which are bloody and mixed with mucus. This should be the question the nurse asks first. Next, the nurse should ask about the pain. The pain with intussusception has a sudden onset and is intermittent and crampy. The appetite of the child generally is poor due to abdominal pressure and pain. Intussusception is not a contagious or infectious disease.

After the nurse teaches a client about ways to reduce the symptoms of premenstrual syndrome, which client statement indicates a need for additional teaching? A) "I've signed up for an aerobic exercise class three times a week." B) "I will make sure to take my estrogen supplements a week before my period." C) "I'll cut down on the amount of coffee and colas I drink." D) "I quit smoking about a month ago, so that should help."

B) "I will make sure to take my estrogen supplements a week before my period." Lifestyle changes such as exercising, avoiding caffeine, and smoking cessation are a key component for managing the signs and symptoms of premenstrual syndrome. Estrogen supplements are not used. If medication is necessary, NSAIDs may be used for painful physical symptoms; spironolactone may help with bloating and water retention.

The nurse recognizes that which client has the greatest risk for suicidal behavior? A) A 16-year-old girl who just failed a math test B) A 16-year-old boy who has had 12 girlfriends over the past year C) A 12-year-old girl whose parents have just gotten a divorce D) A 9-year-old boy who had an uncle who died unexpectedly

B) A 16-year-old boy who has had 12 girlfriends over the past year Suicide is one of the leading causes of death in children 10 to 19 years of age. Adolescent males commit suicide four times more often than do females. Attempted suicide rarely occurs without warning and usually is preceded by a long history of emotional problems, difficulty forming relationships, feelings of rejection, and low self-esteem.

A pregnant woman informs the nurse that her last normal menstrual period was on July 6, 2016. Using Naegele's rule, which of the following would the nurse determine to be the client's estimated date of confinement (EDC)? A) January 9, 2017 B) April 13, 2017 C) April 20, 2017 D) September 6, 2017

B) April 13, 2017 The EDC is calculated as April 13, 2017. Naegele's rule: First, identify the first day of the last normal menstrual period. Then, subtract 3 months and add 7 days. Finally, adjust the year, if needed.

The nurse is caring for an adolescent with anorexia nervosa. What intervention should the nurse include in the care of this client? A) Take daily weights to document weight gain. B) Encourage the client and the client's family to participate in family therapy. C) Encourage at least 30 minutes of exercise daily to help the client feel like he or she is not gaining weight too fast. D) Encourage the family to vary their daily routine at home so the client does not get bored.

B) Encourage the client and the client's family to participate in family therapy. Both the client and the client's family need to be included in the plan of care along with therapy sessions to help better treat the adolescent. Clients should be weighed weekly, not daily. The focus needs to move to better nutrition and a goal of a 0.5 to 2 lb (0.25 to 1 kg) weekly weight gain. A structured routine of meals and snacks needs to be established. Daily exercise is not encouraged.

A nurse is working in the prenatal clinic. Which of the following findings would the nurse consider to be within normal limits for a client in the third trimester of pregnancy? A) Diplopia B) Epistaxis C) Bradycardia D) Oliguria

B) Epistaxis Diplopia is sometimes seen in clients with hypertensive illnesses of pregnancy. Correct answer: Epistaxis is commonly seen in pregnant clients. The bleeding is related to the increased vascularity of the mucous membranes. Unless the blood loss is significant, it is a normal finding associated with estrogen. Bradycardia is often seen immediately after delivery but not during the third trimester. Oliguria is seen in clients with pregnancy-induced hypertension (PIH).

The nurse cares for a client diagnosed with urinary incontinence. When implementing the plan for urinary habit training, which action does the nurse take first? A) Provides privacy for the client to toilet B) Establishes client's voiding pattern C) Assists the client to the toilet every 2 hours D) Turns water faucet on when the client is on the toilet

B) Establishes client's voiding pattern Rationale: A. Appropriate action but must 1st determine usual voiding pattern B. Correct answer-keep a record x 3 days of when client voids to determine voiding pattern C. Establish the interval of voiding based on the void pattern; intervals for toileting should not be less than 2 hours D. Encourages client to void; can also flush the toilet

A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? A) Type and cross-match her blood. B) Insert an internal fetal monitor electrode. C) Administer an oral stool softener. D) Assess her complete blood count.

B) Insert an internal fetal monitor electrode. This action is inappropriate. When a client has a placenta previa, nothing should be inserted into the vagina

In caring for a child with a urinary tract infection, the nurse would perform all of the following nursing interventions. Which two interventions would the nurse identify as the priority? A) Record and report any indications of urinary burning, frequency, or urgency. B) Observe the child for signs of any reactions to the antibiotics. C) Observe for possible indications of sexual abuse. D) Collect a "clean catch" voided urine. E) Teach girls to wipe from front to back. F) Instruct caregivers to avoid bubble baths, especially in young girls.

B) Observe the child for signs of any reactions to the antibiotics. D) Collect a "clean catch" voided urine. The nurse would collect the "clean catch" voided urine specimen before any treatment is started to increase the likelihood of being able to identify the bacterium causing the infection. A priority when giving antibiotics is to always observe for signs of any adverse reaction to the medication. Reporting and recording urinary symptoms and observing for possible sexual abuse would be appropriate but not the priority. Instructing caregivers about avoiding bubble baths and teaching girls to wipe from front to back would be important later in the care of the child.

The nurse notes each of the following findings in a 12-week-gestation client. Which of the findings would enable the nurse to tell the client that she is probably pregnant? A) Fetal heart rate via Doppler B) Positive pregnancy test C) Positive ultrasound assessment D) Absence of menstrual period

B) Positive pregnancy test A fetal heart rate is a positive sign of pregnancy. A positive pregnancy test is a probable sign of pregnancy. It is not a positive sign because the hormone tested for—human chorionic gonadotropin (hCG)—may be produced by, for example, a hydatidiform mole (molar pregnancy). A positive ultrasound is a positive sign of pregnancy. Amenorrhea is a presumptive sign of pregnancy.

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? A) Conduction B) Radiation C) Convection D) evaporation

B) Radiation Answer b: Rationale: Conduction: transfer of heat from one object to another when the 2 objects are in direct contact with each other Convection: flow of heat away from the body surface to cooler surrounding air or to air circulating over a cooler surface Evaporation: involves the loss of heat when a liquid is converted to a vapor Radiation: involves the loss of body heat to cooler, solid surfaces that are in proximity but not in contact with the newborn

The school nurse is presenting a class on substance abuse to a group of school-age children. Which tactic would be least effective in persuading these children to not begin using illegal substances? A) Explain how drugs affect their bodies. B) Tell the children that they can die if they use them. C) Openly discuss the good, as well as the bad, parts of substance abuse to give the child an honest picture. D) Set clear rules and consequences for breaking the rules related to drug abuse.

B) Tell the children that they can die if they use them. Adults need to be honest when talking with school-age children about substance abuse, but they should not use "scare" techniques because these techniques make the child more curious and make substance abuse seem more thrilling and dangerous. Setting clear rules regarding substance abuse makes the child less likely to begin using them because they understand the consequences of use. Knowing how drugs affect their bodies also helps them understand that drug usage is bad.

The nurse notes in a term newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria? A) The jaundice occurred within the first 24 hours after birth. B) The bilirubin peaked between days 3 and 5 after birth. C) The bilirubin level rose 6 mg/dL to 13 mg/dL over the last 24 hours. D) The conjugated bilirubin is higher than the unconjugated bilirubin.

B) The bilirubin peaked between days 3 and 5 after birth. Answer B Rationale: Peak bilirubin levels are reached between days 3-5 in the full term newborn Peak bilirubin levels are reached between days 5-7 in the preterm newborn Newborns of Asian, Native-American descent have higher rates Visible when serum concentration is greater 6-7mg/dL Pathologic Jaundice appears IMMEDIATELY after birth or within first 24 hours Unmonitored and untreated severe hyperbilirubinemia may progress to neurotoxicity (kernicterous) Develops jaundice is cephalocaudal progression first seen in the face and then travels down trunk

A nurse is developing a standard care plan for teen women in an obstetrical clinic. Which of the following client care outcomes would be appropriate to include in the plan of care? A) The teen gravida will have her fetus assessed for chromosomal anomalies. B) The teen gravida will eat a diet high in calcium and iron. C) The teen gravida will deliver her baby before 37 weeks' gestation. D) The teen gravida will gain no more than 25 pounds during the pregnancy.

B) The teen gravida will eat a diet high in calcium and iron. High rates of genetic anomalies are not seen in teen pregnancies; therefore, it is unnecessary for teen gravidas to have routine assessments for fetal chromosomal defects. Teens tend to consume less calcium and iron than they should consume during their pregnancies; therefore, this is an appropriate patient-care outcome for pregnant teens. Because teen pregnancies frequently end prematurely, the appropriate patient care goal should be: The teen gravida will deliver a full-term baby. Pregnant teens should gain the same amount of weight that adult gravidas should gain unless the teens are above or below normal weight for height.

The nurse is assessing a hospitalized child diagnosed with nephrotic syndrome. What set of assessments is most important for the nurse to complete to help identify hypoalbuminemia in this child? A) heart and lung sounds B) heart rate and blood pressure C) respiratory rate and heart rate D) blood pressure and oxygen saturation

B) heart rate and blood pressure In nephrotic syndrome, hyperalbuminemia occurs with a loss of protein and albumin in the bloodstream. This causes many fluid shifts from the bloodstream (intravascular) to the interstitial tissues. The result is edema, as the fluid in the interstitial spaces increases. This leaves the intravascular fluid decreased or depleted, causing hypovolemia. The best set of assessments for this condition is to assess the heart rate and blood pressure. These will indicate hypovolemia from the fluid shifts occurring. The respiratory rate and the work of breathing are assessed for fluid overload in the lungs. The heart sounds and the lung sounds are assessed for fluid overload, not decreased fluid. Assessing the oxygen saturation is only necessary if there are adventitious lung sounds or increased work of breathing.

A nurse in the sexual health clinic assesses a female client and notes wart-like lesions on the genital area and rectum. Which diagnosis best correlates with these findings? A) trichomoniasis infection B) human papillomavirus C) Syphilis D) genital herpes

B) human papillomavirus HPV presents itself with wart-like lesions that are soft, moist, or flesh colored and appear on the vulva and cervix, and inside and surrounding the vagina and anus. The other diagnoses do not present with wart-like lesions.

The nurse educator is teaching new nurses on risk factors for intimate partner violence to watch for when caring for pregnant clients. Which risk factors will the nurse include in the teaching? Select all that apply. A) advanced maternal age B) uncertainty of the baby's father C) unwanted pregnancy D) unemployed mother E) neither parent attended college

B) uncertainty of the baby's father C) unwanted pregnancy D) unemployed mother Risk factors for intimate partner violence during pregnancy include doubts about paternity, an unwanted pregnancy, either or both parents being unemployed, young age during pregnancy, and having less than a high school education. Other risk factors include heavy drinking by the partner, history of abuse, cohabitation, jealousy, change in woman's shape, stress of becoming a father, previous isolation from family, and financial hardships.

A G4P4 client is recovering from dystocia for which oxytocin was administered to assist with the contractions. On assessment 24 hours later, the nurse notes moderate to heavy lochia with numerous large clots and the uterus deviated to the right, above the umbilicus, and firm. Which action should the nurse prioritize? A. Initiate fundal massage. B. Ensure that her bladder is empty. C. Draw blood for H&H STAT. D. Encourage breast-feeding to stimulate uterine contractions.

B. Ensure that her bladder is empty. Correct Answer B Rationale-many postpartum women do not sense the need to void even if their bladder is full. In this situation the bladder can become distended and displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to excessive bleeding. Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections. Assess the bladder for distention and adequate emptying after efforts to void. Palpate the area over the symphysis pubis. If empty, the bladder is not palpable. Palpation of a rounded mass suggests bladder distention. Also percuss the area: a full bladder is dull to percussion. If the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. Take Note! Note the location and condition of the fundus; a full bladder tends to displace the uterus up and to the right. After the woman voids, palpate and percuss the area again to determine adequate emptying of the bladder.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100.8° F (38.2° C). Which action would be most appropriate for the nurse to take? A. Continue monitoring the woman's temperature every 4 hours; this finding is normal. B. Notify the health care provider about this elevation; this finding reflects infection. C. Obtain a urine culture; the woman most likely has a urinary tract infection. D. Inspect the perineum for hematoma formation.

B. Notify the health care provider about this elevation; this finding reflects infection. Answer B Rationale-A temperature above 100.4°F (38°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. An elevated temperature can identify maternal sepsis, which results in significant maternal morbidity and mortality worldwide. This answer is incorrect. This finding is not normal C. This answer is not priority and assumes that the infection is caused by UTI. The information in this stem does not support this assumption D. This answer is not priority and the information in the question stem does not support a hematoma formation (post-partum bleeding).

The nurse provides care for a client diagnosed with cervical cancer. The nurse notes the client appears to have a poor appetite. Which intervention by the nurse is best? A. Provide a high-fat snack B. Provide small, frequent feedings C. Provide additional fluids at meal times D. Provide food when the client requests it

B. Provide small, frequent feedings Rationale: A. Clients with cancer may have protein-energy malnutrition that needs to be corrected. High protein, high energy should be provided. High-fat snacks provide only empty calories B. Correct answer-the cardinal rule for increasing caloric intake for the client who has inadequate intake or anorexic is to provide small, frequent feedings. Food is often tolerated better in the morning. If the client has decreased taste, the nurse can increase flavor and seasoning in the food. C. Fluids are important but it is more important to offer small, frequent, high-protein, high energy meals/snacks to improve caloric intake D. Clients needs to be encouraged to eat when they are experiencing anorexia. The nurse will assess for food likes and dislikes and be aware of the timing of meals

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? A. blood pressure B. pulse rate C. cardiac output D. hematocrit

B. pulse rate Correct answer B-Vital signs will start to deviate from normal, tachycardia being the first vital sign to increase (100 to 120 beats per minute), which is followed by an increased respiratory rate (20-24 breaths per minute). Class III hemorrhage is 30 to 40% of total blood volume loss. Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Any pulse rate higher than 100 bpm warrants further investigation to rule out complications

Which client most likely has ulcerative colitis rather than Crohn disease? A) 14-year-old female with full-thickness chronic inflammation of the intestinal mucosa B) 18-year-old male with abdominal pain C) 16-year-old female with continuous distribution of disease in the colon, distal to proximal D) 12-year-old with oral temperature of 101.6° F (38.7° C)

C) 16-year-old female with continuous distribution of disease in the colon, distal to proximal Ulcerative colitis is usually continuous through the colon while the distribution of Crohn disease is segmental. Crohn disease affects the full thickness of the intestine while ulcerative colitis is more superficial. Both conditions share age at onset of 10 to 20 years, with abdominal pain and fever in 40% to 50% of cases.

The nurse understands which medication is most likely to be prescribed for a client with a diagnosis of gonorrhea? A) Penicillin vaginal suppositories B) Penicillin G benzathine IM in divided doses once a week C) Ceftriaxone IM plus doxycycline PO for 7 days D) Ampicillin PO

C) Ceftriaxone IM plus doxycycline PO for 7 days (ceftriaxone treats gonorrhea, doxycycline treats chlamydia; must treat both to treat gonorrhea) Rationale: A. PCN vaginal suppositories are not used to treat gonorrhea B. This is the treatment of choice for syphilis C. Correct answer-The CDC recommends a one time dose of ceftriaxone IM plus doxycycline for 7 days as the primary treatment of gonorrhea for non-pregnant clients D. Oral ampicillin is not a treatment for gonorrhea What is the treatment choice for pregnant women diagnosed with gonorrhea? Ceftriaxone IM and Azithromycin PO (not doxycycline)

A nurse is conducting a class at a women's clinic about reproductive cancers. When describing the incidence of reproductive tract cancers in pregnant women, which information would the nurse include? A) Ovarian cancer is detected much later in the pregnant woman because of the hormonal changes that are occurring. B) Many cases of endometrial cancer are detected in pregnant women because of the increase in surveillance. C) Cervical cancer is more common in the pregnant population than other reproductive cancers. D) Reproductive cancers overall are more common in pregnant women.

C) Cervical cancer is more common in the pregnant population than other reproductive cancers. The most frequent malignancies diagnosed during pregnancy are breast cancer, cervical cancer, thyroid, hematologic malignancies (lymphomas and acute leukemia), and melanoma. Breast cancer is the most common cancer diagnosed in pregnant women which affects approximately one in 3,000 pregnancies. However, cervical cancer is more common in the pregnant population than other reproductive malignancies, and it can affect the woman's health status and the pregnancy. Ovarian cancer occurring during pregnancy is found at early stages and is associated with a good prognosis for both the mother and newborn. Few cases of endometrial cancer would be detected during the relatively young pregnancy population since routine screening is currently not recommended in the general population. Reproductive tract cancers can occur in a pregnant woman, but their incidence is highly variable.

A woman who is being seen in the prenatal clinic is found to be 12 weeks pregnant. She confides to the nurse that she is afraid her baby may be permanently damaged because she takes penicillin every day to prevent rheumatic fever. In addition to advising the client's primary healthcare provider of the information, which of the following actions by the nurse would be appropriate? A) Advise the client that very few medications cross the placenta, so it is unlikely that the baby has been affected. B) Refer the client to a perinatologist for a high-resolution ultrasound scan to see if the baby was affected. C) Consult a medication reference text. D) Recommend the client abort the fetus.

C) Consult a medication reference text. This statement is untrue. All but a very few medications cross the placental barrier. The nurse should consult a medication reference text first. In addition to advising the client's primary healthcare provider, the nurse should consult a medication reference text. Whether the text states that the fetus will be affected or not, it is inappropriate for the nurse to advise the client to abort her fetus

A nurse is performing an assessment on a pregnant client. Which of the following findings would lead the nurse to report to the obstetrician that the client may be experiencing intrauterine growth restriction (IUGR)? A) Leopold's maneuvers: hard round object in the fundus, flat object on left of uterus, small parts on right of uterus, soft round object above the symphysis. B) Weight gain: 6-pound increase over 4-week period C) Fundal height measurement: 22 cm at 26 weeks' gestation D) Alpha-fetoprotein (AFP) assessment: level of one-half normal, accompanied by complaints of severe nausea and vomiting

C) Fundal height measurement: 22 cm at 26 weeks' gestation A. This baby is in the breech position. This is not a sign of IUGR. B. This weight gain is slightly above normal. This is not a sign of IUGR. C. Correct Answer: The fundal height at 26 weeks should be approximately 26 cm. The fundal height, therefore, is below expected. This client may be experiencing IUGR. D. A low AFP level is seen in clients whose babies have spina bifida and other central nervous system defects.

A woman who has had no prenatal care was found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4,500 grams. The nurse concludes that which of the following complications of pregnancy likely contributed to these findings? A) Pyelonephritis B) Pregnancy-induced hypertension C) Gestational diabetes D) Abruptio placentae

C) Gestational diabetes Pyelonephritis does not lead to the development of hydramnios or macrosomia. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

A nurse is teaching a class to young women on contraception. When instructing a class about estrogen-progestin contraceptives, the nurse stresses to the participants that which of the following findings should be reported to the HCP? A) bleeding, nausea, rash B) tachycardia, weakness, syncopal episodes C) HTN, calf tenderness, breast nodules D) bradycardia, pruritus, changes, HTN

C) HTN, calf tenderness, breast nodules Rationale: A. breakthrough bleeding and nausea are common side effects; but a rash is not commonly reported. B. These side effects are not commonly reported. D. Bradycardia and pruritus are not commonly reported; hypertension is. Practice Connection: COCs are used to prevent pregnancy and to resolve irregular menstruation, pain or heavy periods, endometriosis, acne and PMS. They work by preventing ovulation. Monophasic pills all contain the same balance of hormones. With phasic pills, two or three different types of pills with a different balance of hormones are taken each month. Common side effects include intermenstrual spotting, nausea, breast tenderness, headaches and migraine; weight gain, mood changes, missed period, decreased libido, and vaginal discharge

A newborn is born diagnosed with an omphalocele. What will the nurse prioritize in the care plan during the preoperative period? A) Care for the infant in a sterile isolette. B) Swaddle the infant in sterile newborn blankets. C) Place the infant in a sterile bowel bag. D) Place the covered infant under the radiant warmer.

C) Place the infant in a sterile bowel bag. Answer C Rationale: An omphalocele is a defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac. Nursing management of newborns with omphalocele focuses on preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss, and protecting the exposed abd contents from trauma and infection. These objectives can be accomplished by placing the infant a sterile drawstring bowel bag.

A nurse is preparing a presentation on the menstrual cycle for a health fair. Which phase will the nurse illustrate as producing progesterone? A) Menstrual B) Proliferative C) Secretory D) Ischemic

C) Secretory The corpus luteum begins to produce progesterone during the secretory phase of the menstrual cycle. The follicle develops during the menstrual phase and begins to secrete estrogen. The proliferative phase continues secreting estrogen and progesterone. There are no hormones secreted during the ischemic phase, which will result in the endometrium sloughing off and leaving the uterus.

The nurse has taken a health history on four multigravid clients at their first prenatal visits. It is high priority that the client whose first child was diagnosed with which of the following diseases receives nutrition counseling? A) Development dysplasia of the hip B) Dwarfism C) Spina bifida D) Muscular dystrophy

C) Spina bifida The etiology of developmental dysplasia of the hip is unrelated to the mother's nutritional status. Dwarfism is an inherited defect. Its etiology is unrelated to the mother's nutritional status. The incidence of spina bifida is much higher in women with poor folic acid intake. It is a priority that this client receives nutrition counseling. Most forms of muscular dystrophy are inherited. Their etiologies are unrelated to the mother's nutritional status.

A primigravid client is 39 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit? A) Nausea B) Dysuria C) Urinary frequency D) Intermittent diarrhea

C) Urinary frequency Nausea usually is not seen in the third trimester- Nausea is usually related to increased levels of HCG happens in early pregnancy. Dysuria is not a normal finding at any time during a pregnancy. The possibility of a urinary traction infection (UTI) should be considered. Correct Answer: Urinary frequency recurs at the end of the third trimester. As the uterus enlarges, it again compresses the bladder, causing urinary frequency. Diarrhea is not a normal finding at any time during a pregnancy.

Which finding by the nurse may indicate increased intracranial pressure in an infant? A) overflow voiding B) bulging fontanelle when crying C) high-pitched cry D) minimal lower extremity movement

C) high-pitched cry Answer C Rationale: In Infants Early signs and symptoms of increased ICP in infants include: Bulging, tense fontanelle with or without crying Wide sutures and increased head circumference Dilated scalp veins High-pitched cry

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions? A) when there is no cardiac activity detectable B) when no spontaneous respiratory effort is visible C) when the heart rate is less than 60 beats per minute D) when the pulse oximetry reading is less than 80%

C) when the heart rate is less than 60 beats per minute Answer C Rationale: In deciding when to initiate chest compressions, consider the heart rate, the change of heart rate, and the time elapsed after initiation of resuscitative measures. Because chest compressions may diminish the effectiveness of ventilation, do not initiate them until lung inflation and ventilation have been established. The general indication for initiation of chest compressions is a heart rate <60 bpm despite adequate ventilation with 100% oxygen for 30 seconds. Although it has been common practice to give compressions if the heart rate is 60 to 80 bpm and the heart rate is not rising, ventilation should be the priority in resuscitation of the newly born.

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question? A. Wear compression stockings. B. Plan long rest periods throughout the day. C. Take a combined oral contraceptive daily. D. Take aspirin as needed.

C. Take a combined oral contraceptive daily. Correct Answer C-CDC recommends that postpartum women not use COC (combined oral contraceptives) during first 21 days due to DVT risk and should not use COC for first 6 weeks due to estrogen content may interfere with establishing milk production. After 42 days postpartum, there are no restrictions on the use of COC based on postpartum status.

4 week old, mom crying, small ASD

Condition spontaneously resolves

Which of the following statements is appropriate for the nurse to say to a prenatal patient with complete placenta previa? A) "During the second stage of labor, you will need to bear down." B) "You should ambulate in the halls at least twice each day." C) "The doctor will likely induce your labor with oxytocin." D) "Please report to a nurse if you feel any back discomfort."

D) "Please report to a nurse if you feel any back discomfort." This response is inappropriate. This client will be delivered by cesarean section. This response is inappropriate. Clients with placenta previa are usually on bed rest. This response is inappropriate. This client will be delivered by cesarean section. Labor often begins with back pain. Labor is contraindicated for a client with complete placenta previa. Beware of adding the percentage in the stem. You have all the information needed to answer the question

The nurse working in an outpatient obstetrical office assesses four primigravid clients. Which of the client findings would the nurse highlight for the physician? A) 15 weeks, denies feeling fetal movement B) 20 weeks, fundal height at the umbilicus C) 25 weeks, complains of excess salivation D) 30 weeks, states that her vision is blurry

D) 30 weeks, states that her vision is blurry This finding is normal. Quickening is usually felt between 16 and 20 weeks' gestation. This finding is normal. The fundal height at 20 weeks' gestation is usually at the level of the umbilicus. Excess salivation is a normal, albeit annoying, finding. Blurred vision is a sign of hypertensive illness of pregnancy, also called pregnancy-induced hypertension (PIH). This finding should be reported to the woman's healthcare practitioner.

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize? A) Report tachypnea B) Recheck blood pressure in 15 minutes. C) Put warming blanket over infant. D) Document normal findings.

D) Document normal findings. Answer D Rationale: Temperature: 97.7-99.5 F (36.5-37.5 C) Heart rate: 110-160 bpm can increase up to 180 bpm when crying Respiratory: 30-60 breaths/min at rest; will increase with crying Blood pressure: 50-75mmHg systolic and 30-45 mm Hg diastolic

The nurse is caring for a second-trimester client who is at high risk for preterm labor. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis? A) Human relaxin levels B) Amniotic fluid levels C) Alpha-fetoprotein levels D) Fetal fibronectin levels

D) Fetal fibronectin levels Relaxin levels are rarely assessed. In addition, they are unrelated to the incidence of preterm labor. Amniotic fluid levels are not directly related to the incidence of preterm labor. Alpha-fetoprotein levels are not related to the incidence of preterm labor. A rise in the fetal fibronectin levels in cervical secretions has been associated with preterm labor

A 1-year-old child below 5% on the growth chart has been admitted to the hospital. The nursing diagnosis for this child is Imbalanced nutrition, less than body requirements, related to inadequate intake secondary to emotional deprivation. Which nursing intervention would be most effective for this child? A) Contact child protective services to report abuse. B) Discourage the parents from visiting their child. C) Maintain strict intake and output plus calorie count. D) Have one consistent nurse feed and care for the child.

D) Have one consistent nurse feed and care for the child. This child has failure to thrive and needs a consistent caregiver to help nurture and feed the baby, bringing the baby back to a healthy nutritional and emotional status. Parents need to be encouraged to visit as much as possible and then help feed and interact with the infant. It is too soon to contact CPS, as there needs to be time to assess how the parents respond to their child. It is a good idea to keep strict intake and output plus calorie count, but this does not improve the child's condition.

A client with 4+ protein and 4+ reflexes is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? A) High leukocyte count B) Explosive diarrhea C) Fractured pelvis D) Low platelet count

D) Low platelet count High leukocyte count is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. Explosive diarrhea is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. A fractured pelvis is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome.

The nursing instructor is teaching a student about the management of children with cognitive impairment. The student demonstrates understanding when making which statement? A) Children with cognitive impairment do not need to learn socialization skills. B) Play therapy is used rarely with children with cognitive impairment. C) Behavior management is easily provided by anyone caring for children with cognitive impairment. D) No specific medical interventions exist for children with cognitive impairment.

D) No specific medical interventions exist for children with cognitive impairment. Common interventions for children with cognitive impairment include behavior management (e.g., teaching life and socialization skills), involving them in play therapy, and teaching about human sexuality. Behavior management and play therapy are provided by advanced practice nurses. No specific medical interventions exist for cognitive impairment.

The nurse instructs a client who recently had a modified radical mastectomy. The nurse explains it is very important for the client to exercise the affected arm. Which statement by the nurse is the most important reason for the client to exercise the arm? A) Increases muscle strength and diameter B) Maintains body balance C) Limits full range of motion D) Prevents lymphedema

D) Prevents lymphedema Rationale: A. The primary purpose for exercising the affected arm after a mastectomy is to prevent lymphedema. Lymphedema is the pooling of lymph circulation in the involved arm after the removal of the lymph glands. B. The nurse should advise the client not to sleep on the affected arm and encourage use of arm in ADLs. C. Early use of the affected arm and hand will prevent atrophy and contractures and will enhance fluid return. The client should be encouraged to perform full ROM , not limit ROM D. Correct answer-postoperatively-the nurse will encourage the client to perform prescribed exercises and elevate extremity on affected side to prevent lymphedema. Exercising the arm muscles pump lymph fluid back into circulation. The client should position the arm on the pillow with each joint higher than the proximal joint elevation

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction? A) Temp: 99.4° F (37.4° C), HR 90, RR 18, BP 112/67 B) Temp: 97.0° F (36.1° C), HR 80, RR 20, BP 120/72 C) Temp: 100.2° F (38° C), HR 65, RR 22, BP 130/78 D) Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

D) Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 Answer D: Rationale-Assess the woman's blood pressure and compare it with her usual range. Report any deviation from this range. Immediately after childbirth, the blood pressure should remain the same as during labor. An increase in blood pressure could indicate gestational hypertension, whereas a decrease could indicate shock or orthostatic hypotension or dehydration, a side effect of epidural anesthesia. Blood pressure readings should not be higher than 140/90 mm Hg or lower than 85/60 mmHg (King et al., 2015). Blood pressure also may vary based on the woman's position, so assess blood pressure with the woman in the same position every time. Be alert for orthostatic hypotension, which can occur when the woman moves rapidly from a lying or sitting position to a standing one.

A nurse is caring for a client who complains of itching of the vulva and a frothy grey vaginal discharge that "smells fishy." The nurse knows that these clinical s/s are associated with which of the following? A) Chlamydia B) Genital herpes C) Syphilis D) Trichomoniasis

D) Trichomoniasis Rationale: Typically, a female client with trichomoniasis experiences itching, burning, redness or soreness of the genitals; discomfort with urination; and a change in character or volume of vaginal discharge (i.e. increased volume or thin discharge). Vaginal discharge can be clear, white, grey, greenish but is classically described as malodorous, with an unusual fishy smell. Trich may be treated with metronidazole (2g in a single dose). This medication may be taken during pregnancy. Clients should not drink alcohol after 24 hours of taking medication. Disulfuram-like drug reaction- is a drug that causes an adverse reaction to alcohol leading to nausea, vomiting, flushing, dizziness, throbbing headache, chest and abdominal discomfort, and general hangover-like symptoms among others. A. Chlamydia is often asymptomatic until the infection has progressed to cause PID or other complications. B. GH causes a painful vesicular lesion C. Syphilis- during the initial stage, clients will typically have a painless genital ulcer (chancre) at the site of inoculation. During later stages; a rash, fever, sore throat, and swollen lymph glands may develop.

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice? A) bilirubin overproduction B) decreased bilirubin conversion C) impaired bilirubin excretion D) bilirubin hyperexcretion

D) bilirubin hyperexcretion Answer D: Rationale: The causes of newborn jaundice can be classified into 3 groups based on mechanism of accumulation: Bilirubin overproduction Decreased bilirubin conjugation Impaired bilirubin excretion

To help detect potential disease processes in the breasts, the nurse develops educational programs focusing on: A) need for clinical examination. B) need for mammography. C) breast self-examination. D) breast awareness.

D) breast awareness. Breast awareness is stressed. Breast awareness refers to a woman being familiar with the normal consistency of both breasts and the underlying tissue. This emphasis is now on awareness of breast changes, not just discovery of cancer. Research has shown that BSE plays a small role in detecting breast cancer compared with self-awareness. However, doing BSE is one way for a woman to know how her breasts normally feel so that she can notice any changes that do occur

The nurse cares for a client after a breast biopsy. After the procedure, it is most important for the nurse to take which action? A. Apply ice to the area B. Reposition the client for comfort C. Carefully transport specimen to the lab D. Observe for bleeding

D. Observe for bleeding Rationale: A. Avoid cold to prevent nipple contractions that may stress the incision site B. For female clients, supportive bra should be worn continuously for one week; take mild analgesic medication for pain; or heating pad C. First, take care of the patient D. Correct Answer-in the initial post-biopsy period, ligation of the artery or vein is the greatest risk; nurse should observe for frank bleeding, pallor, cold, clammy skin and an increased pulse/and /or decreased blood pressure. Always assess before implementation

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? A. prolactin B. estrogen C. progesterone D. oxytocin

D. oxytocin Correct answer D: Rationale Breast milk production can be summarized as follows: Prolactin levels increase at term with a decrease in estrogen and progesterone levels. Estrogen and progesterone levels decrease after the placenta is delivered. Decrease in estrogen is responsible for breast engorgement Prolactin is released from the anterior pituitary gland and initiates milk production. Oxytocin is released from the posterior pituitary gland to promote milk let-down. Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release

When providing care for a toddler w/ hemophilia preparing for elective procedure, what is priority?

Ensure all side rails are padded

Nurse is providing care for adolescent w/ acne, expresses sadness, what should you say

How are you feeling let's talk about it

School age kid cystic fibrosis, nutrition met how do you know

In 20th percentile for height and weight

Infant passenger in motor vehicle accident, bulging fontanelle indicates

Increased ICP

Nurse hears wheezing when listening to a 4 year old. What condition is ruled out?

Upper respiratory infection

Which assessment findings of the fetus during labor are reassuring? Select all that apply. a. Variability between 18-20 bpm b. Late decelerations c. Fetal heart baseline of 130 bpm d. Repeated variable decelerations e. Gradual increase in the fetal heart rate baseline

a. Variability between 18-20 bpm c. Fetal heart baseline of 130 bpm A,C-represent a reassuring baseline (normal heart rate 110-160) and moderate variability between 6-25 bpm

The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism (AFE). Which findings would the nurse assess? Select all that apply. a. significant difficulty breathing b. hypertension c. tachycardia d. pulmonary edema e. bleeding with bruising

a. significant difficulty breathing c. tachycardia d. pulmonary edema e. bleeding with bruising A,C,D,E Rationale-The clinical appearance of AFE is varied, but most women report difficulty breathing. Other symptoms include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation (DIC), pulmonary edema, seizures, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis? a. sutures b. fontanelles c. frontal bones d. biparietal diameter

a. sutures A Rationale- Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Some diameters shorten, whereas others lengthen as the head is molded during the labor and birthing process. This malleability of the fetal skull may decrease fetal skull dimensions by 0.5 to 1 cm (King, et al., 2015). After birth, the sutures close as the bones grow and the brain reaches its full growth.

A woman arrives in the L & D unit in the beginning early phase with her contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the woman in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the woman for which priority assessment caused by a rapid birth? a. Assess bladder for fullness. b. Check perineal area frequently for bleeding. c. Assess the woman's breathing and intervene if necessary. d. Assess and administer pain medication as needed.

b. Check perineal area frequently for bleeding. B-Rationale: Precipitate labor is labor that is completed in less than 3 hours from the start of contractions to birth. Not only can labor be too slow, but it can be abnormally rapid. The prevailing opinion has been that too rapid a labor can result in maternal injury and place the fetus at risk for traumatic or asphyxia insults (Suzuki, 2015). Women experiencing precipitate labor typically have soft perineal tissues that stretch readily, permitting the fetus to pass through the pelvis quickly, or abnormally strong uterine contractions. Maternal complications are rare if the maternal pelvis is adequate and the soft tissues yield to a fast fetal descent. However, if the fetus delivers too fast, it does not allow the cervix to dilate and efface, which leads to cervical lacerations and the potential for uterine rupture. Potential fetal complications may include head trauma, such as intracranial hemorrhage or nerve damage, and hypoxia due to the rapid progression of labor (Cunningham et al., 2014). Precipitate labor is an anxiety-producing situation and frequently very painful with little rest between contractions. Continuous monitoring, frequent updates on her labor progress, pain management, and reassurance about her condition can assist in reducing the mother's anxious state of mind. Management includes readiness of the health care team for this rapid birth.

A multiparous woman at 39 weeks' gestation arrives at the labor and delivery unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix with 3cm dilatation, intact membrane. Which nursing action is best? a. Have the client rest in bed on her left side. b. Have the client ambulate in the hall and recheck. c. Send the client home and return if contractions increase d. Admit the client directly to the labor and delivery area

b. Have the client ambulate in the hall and recheck. B Rationale:-Walking with support from the partner (adds the force of gravity to contractions to promote fetal descent) Slow-dancing position with the partner holding the woman (adds the force of gravity to contractions and promotes support from and active participation of your partner) Side lying with pillows between the knees for comfort (offers a restful position and improves oxygen flow to the uterus) Semi-sitting in bed or on a couch leaning against the partner (reduces back pain because fetus falls forward, away from the sacrum) Sitting in a chair with one foot on the floor and one on the chair (changes pelvic shape) Leaning forward by straddling a chair, a table, or a bed or kneeling over a birth ball (reduces back pain, adds the force of gravity to promote descent; possible pain relief if partner can apply sacral pressure) Encourage any position of comfort the woman choses to labor in and give birth. Sitting in a rocking chair or on a birth ball and shifting weight back and forth (provides comfort because rocking motion is soothing; uses the force of gravity to help fetal descent) Lunge by rocking weight back and forth with foot up on chair during contraction (uses force of gravity by being upright; enhances rotation of fetus through rocking) Open knee-chest position (helps to relieve back discomfort)

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. a. current pregnancy history b. fundal height measurement c. support system d. estimated date of birth e. membrane status f. contraction pattern

b. fundal height measurement e. membrane status f. contraction pattern The physical examination typically includes a generalized assessment of the woman's body systems, including hydration status, vital signs, auscultation of heart and lung sounds, and measurement of height and weight. The physical examination also includes the following assessments: Pain level and coping behaviors demonstrated Uterine activity, including contraction frequency, duration, and intensity Fetal status, including heart rate, position, and station Cervical dilation and degree of effacement Status of membranes (intact or ruptured) Assess vital signs: temperature, pulse, respirations, & blood pressure Perform Leopold maneuvers to determine fetal lie Fundal height measurement Ability to ambulate safely

A nurse receives the shift report on four infants. Baby A is 16 hours old, HR 117, RR 32, axillary temperature 98oF (36.6oC), BP 72/43 mm Hg, bilirubin 3.5 mg/dL rooming in with mother; baby B is 8 hours old, HR 152, RR 48, axillary temperature 97.7oF (36.5oC), BP 60/40 mm Hg, bilirubin 3 mg/dL, returning to nursery for night; baby C is 19 hours old, HR 140, RR 45, axillary temperature 98.6oF (37oC), BP 68/45 mm Hg, bilirubin 4 mg/dL, rooming in with mother; baby D is 4 hours old, HR 160, RR 60, axillary temperature 98.6oF (37oC), BP 80/45 mm Hg, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first? baby A baby B baby C baby D

baby C Answer C Rationale: Pathologic jaundice is manifested within the first 24 hours when total bilirubin levels increase by more than 5 mg/dL/day and the total bilirubin level is higher than 17mg/dL in a full term infant. This condition requires intervention.

The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby? a. 1 cm below the symphysis pubis. b. 1 cm above the ischial spine. c. 1 cm below the ischial spine. d. 1 cm above the symphysis pubis.

c. 1 cm below the ischial spine. C Rationale- if the presenting part is above the ischial spines by 1 cm, it is documented as being a -1 station; if the presenting part is below the ischial spines by 1 cm, it is documented as being a +1 station.

The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize? a. Obtain a comprehensive obstetric history. b. Determine plans for labor and the newborn. c. Take blood pressure and determine if clonus or edema are present. d. Assess use of drugs, alcohol, and tobacco during pregnancy.

c. Take blood pressure and determine if clonus or edema are present. Answer C Rationale-Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the copying status of the woman and her partner (Table 14.4). Assessment also focuses on determining the progress of labor. Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down efforts, and crowning (fetal head is visible at vaginal opening; Fig. 14.15). A vaginal examination is completed to determine if it is appropriate for the woman to push. Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so. A, B and D- are done upon admission during latent phase of stage 1 labor

While discussing labor with a client and her partner, the nurse is asked what the best position is for giving birth to the baby. The nurse provides them with information that indicates research has shown which position as the best? a. lying on her back with feet in stirrups b. squatting c. position of comfort for the mother d. semi-Fowler's position

c. position of comfort for the mother Answer C-The medical profession has favored recumbent positions during labor, but without evidence to demonstrate their appropriateness. A recent Cochrane database systematic review reported there is evidence that walking and upright positions in the first stage of labor reduce the length of labor and do not seem to be associated with increased intervention or negative effects on mothers' and babies' well-being. In an upright posture, gravity directs the weight of the fetus and amniotic fluid downward, successively dilating the cervix and the birth canal. Uterine contractions have been shown to be better spaced, stronger and more efficient in dilating the cervix when the mother is in an upright position than when she is supine (Cox & King, 2015). Women should be encouraged to take up whatever position they find most comfortable in the first stage of labor (Cheng & Caughey, 2015a).

A client who is a victim of intimate partner violence fails to report the violence primarily because of which reason? a. The client does not want anyone to know. b. The client thinks it will not happen again. c. The client feels lucky to be alive. d. The client feels responsible for causing the incident.

d. The client feels responsible for causing the incident. The honeymoon phase prevents many victims from reporting intimate partner violence. The victim wants to believe that the partner can really change. The client feels responsible, at least in part, for causing the incident and for the partner's well-being.