evolve practice quiz 1

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? A. Pregnancy induced hypertension. B. Placenta previa. C. Gestational diabetes. D. Postpartum hemorrhage.

A. Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine.

During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next? A.Perform fundal massage. B. Assess blood pressure. C. Notify the healthcare provider. D. Encourage the client to void.

A. Perineal pad saturation within 15 minutes during the early post partum period is indicative of bleeding, which is commonly due to uterine atony and can lead to post-partum hemorrhage. Fundal assessment and massage should be performed (A) first to control bleeding. (B, C, and D) are actions implemented after manually stimulating the fundus to contract.

The father of a newborn tells the nurse, "My son just died." How should the nurse respond? A. "I am sorry for your loss." B. "There is an angel in heaven." C. "I understand how you feel." D. "You can have other children."

A. The nurse should acknowledge the loss with a simple but sincere comment, such as (A), which validates the experience and recognizes the feelings of the parents. Clich s (B and C) or advice (D) do not encourage the bereaved parents to tell their stories but can stifle the further expression of emotion.

A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? A. Amniocentesis. B. Ultrasonography. C. Chorionic villus sampling. D. Maternal serum alpha-fetoprotein.

B Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound.

A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and has not been sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results? A. Having an irregular menstrual cycle. B. Using an anticonvulsant for epilepsy. C. Taking the pregnancy test too early. D. Being under too much stress at work.

B. Anticonvulsants may yield false-positive pregnancy test results (B). Although over-the-counter pregnancy tests can yield positive results as soon as 4 days after implantation, the client's menstrual cycle dates indicate she is 3 weeks late, so implantation, which occurs 6 to 10 days after conception, has not occurred (C). Normal hormonal and menstrual cycles (A) may be influenced by stress (D), but hCG levels and positive pregnancy results are not affected.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? A. Ask the mother why she won't look at the infant. B. Observe the mother for other attachment behaviors. C. Examine the newborn's eyes for the ability to focus. D. Recognize this as a common reaction in new mothers.

B. Parent-infant bonding or attachment is based on a mutual relationship between parent and infant and is commonly established by the "enface position," which is demonstrated by the mother's and infant's eyes meeting in the same plane. To assess for other attachment behaviors, continued observation of the new mother's interactions with her infant (B) helps the nurse determine problems in attachment. (A) may cause undue confusion, stress, or impact the mother's self-confidence. (C) is not indicated. The "enface position" is a significant, early behavior that leads to the formation of affectional ties and should be encouraged (D).

What action should the nurse implement when caring for a newborn receiving phototherapy? A. Reposition every 6 hours. B. Place an eyeshield over the eyes. C. Limit the intake of formula. D. Apply an oil-based lotion to the skin.

B. Phototherapy converts unconjugated bilirubin, which is deposited in the skin, to a water-soluble form that is more easily excreted by the liver. Exposure to the light source can increase the risk for ocular damage, so an eyeshield (B) is placed while the infant is under the light source. To ensure all body surfaces are exposed to the lights, the newborn should be reposition every 2 to 4 hours, not every 6 hours (A). Phototherapy can increase insensible water loss, and to prevent dehydration, fluid intake should be encouraged, not restricted (C). Lotions (D) absorb heat and can potentially cause burns and should not be used on the skin while phototherapy is in progress.

The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? A. Walking. B. Squatting. C. Kneeling. D. Lithotomy.

B. Squatting (B) helps to align the fetus with the pelvic outlet and allows gravity to assist in fetal descent and gives the client an adventitious position for birth. Although walking (A) and kneeling (C) also help to align the fetus with the pelvic outlet and allow for gravity to assist in fetal descent, these do not accomodate birth easily. The predominant position in the United States for physician-attended births is the lithotomy position which requires a woman to be in a reclined position with her legs in stirrups in which gravity has little effect in this position (D).

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first? A. Prepare the client for imminent birth. B. Assess the fetal heart rate and pattern. C. Document the characteristics of the fluid. D. Notify the client's primary healthcare provider.

B. The fetal heart rate and pattern should be assessed (B) to determine compromise of fetal well-being caused by compression or prolapse of the umbilical cord. The intensity and frequency of the uterine contractions often trigger spontaneous rupture of the membranes (SROM), which does not indicate that birth is imminent (A). The healthcare provider should be notified of the client and fetal well-being after evaluation of SROM. Although the characteristics of the amniotic fluid should be documented (C), assessment of fetal response to the SROM is the priority.

The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? A. Obtain a serum glucose level. B. Give the infant medication for pain. C. Feed the newborn 1 ounce of formula. D. Request a genetic consultation.

B. A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture, and an increase in blood pressure are indicative of pain in the neonate, so analgesia should be given for pain (B). The symptoms of hypoglycemia (A) are jitteriness and mottling. The signs of hunger include rooting, tongue extrusion and possibly crying (C). A high-pitched shrill cry is associated with neurologic and genetic anomalies (D).

A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement? A. Emphasize that food and fluid intake should stop. B. Tell the woman to stay home until her membranes rupture. C. Ask the client to describe why she thinks she is in labor. D. Suggest the client to come to the hospital for labor evaluation.

C. Assessment, the first step of the nursing process, should include specific questions to determine if the woman is in labor (C). Current research does not support stopping oral intake (A). Spontaneous rupture of membranes (SROM) may not occur until labor has progressed, so (B) is not indicated. The client can describe over the phone what is happening, so (D) may not be necessary at this time.

A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? A. Contraction stress test. B. Internal fetal monitoring. C. Abdominal ultrasound. D. Lecithin-sphingomyelin ratio.

C. Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B and D) are invasive procedures that increase the risk for premature onset of labor, and are not indicated at this client's gestation.

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? A. Document the color of the lochia. B. Observe maternal vital signs. C. Assist the client to the bathroom. D. Notify the healthcare provider.

C. Fundus displacement commonly occurs in the early hours of the postpartum period due to urinary retention, so assisting the client to the bathroom (C) to void should be implement next. (A and B) can be completed after the client's bladder is emptied. (D) should only be implemented if the fundus does not become firm or lochial bleeding continues after the bladder is emptied.

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? A. Oral contraceptives prevent a reoccurrence of a molar pregnancy. B. Pregnancy within 1 year decreases the chances of a future successful pregnancy. C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. D. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation.

C. The major risk after a molar pregnancy is the development of choriocarcinoma, which is detected by measuring the same hormone (hCG) that the body produces during pregnancy. Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent pregnancy for a year since it interferes with monitoring the return of hCG levels (C) to normal. (A, B, and D) are inaccurate.

A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to provide? A. "Don't be sad. You'll need to be strong to care for your healthy baby." B. "Do you want to go to the nursery and see your baby?" C. "I am sorry for your loss. Do you want to talk about it?" D. "It is always sad to lose a baby. Would you like me to call your minister?"

C. The nurse should recognize the client's grief and offer an opportunity for the client to discuss her feelings (C). Telling the client not to be sad and that she needs to be strong (A) is invalidating and instructive by the nurse. (B and D) are incorrect responses because they deny the client's expressed grief and attempt to change the subject.

Which action is most important for the nurse to implement for a client at 36-weeks gestation who is admitted with vaginal bleeding? A. Monitor uterine contractions. B. Apply disposable pads under the client. C. Determine fetal heart rate and maternal vital signs. D. Obtain blood samples for hemoglobin hematocrit levels.

C. The priority nursing action is assessment of the fetal heart rate and maternal vital signs (C) to evaluate the impact of blood loss in the mother and fetus. Although monitoring uterine activity (A), applying pads to assess bleeding amount (B), and obtaining samples for hemoglobin and hematocrit levels (D) should be implemented, these are not as important as assessing maternal and fetal well-being.

A client in labor receives an epidural block. What intervention should the nurse implement first? A. Encourage oral fluids. B. Assess contractions. C. Monitor blood pressure. D. Obtain a radial pulse.

C. The risk for maternal hypotension is commonly increased by an epidural, so blood pressure should be monitored immediately after the first epidural dose (C) and for 15 minutes thereafter. Oral fluids should be encouraged to help keep the client hydrated (A), but the first action is to evaluate the client for side effects of the epidural block. Although (B and D) should be continuously monitored after an epidural, the first objective sign of epidural precipitated vasodilation is hypotension.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A. The kidneys and renal function are not fully developed. B. Warmth promotes sleep so the infant will grow quickly. C. A large body surface area favors heat loss to the environment. D. The thick layer of subcutaneous fat is inadequate for insulation.

C. Thermoregulation, heat regulation, is critical to the survival of a neonate because the newborn's larger surface area (C) per unit of weight predisposes to heat loss. While keeping the infant warm may help the infant to sleep, it promotes transitional homeostasis, not growth (B). (A) is unrelated to cold stress of the newborn. (D) does not support the metabolic cascade that results from neonatal heat loss.

Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? A. Brighten the lighting so the mother can view the infant. B. Complete the newborn assessment as quickly as possible. C. Provide positive reinforcement for maternal care of infant. D. Encourage early initiation of breast or formula feeding.

D is the best of the interventions listed to encourage maternal-infant bonding. (A, B, and C) are all methods of promoting maternal-infant bonding but are not usually as effective as initiating infant feeding.

Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? A. Cervix dilated 2 cm and 50% effaced. B. Score of 8 on the biophysical profile. C. Fetal heart rate of 116 beats per minute. D. One fetal movement noted in an hour.

D. A count of less than three fetal movements within 1 hour (D) warrants further evaluation using nonstress or contraction stress testing, biophysical profile, or a combination of these tests. A cervical exam of 2 cm and 50% effacement (A) and a fetal heart rate of 116 (C) are normal findings. A score of 8 on a biophysical profile (B) indicates a normal infant with low risk for chronic asphyxia.

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? A. Blood pressure of 100/60 mm Hg. B. Fetal heart rate of 120 to 125 beats/minute. C. Contractions occurring every 30 minutes. D. Respiratory rate of 11 breaths/minute.

D. A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute (D) should be reported to the healthcare provider. (A, B, and C) are expected findings for a 36-week gestation client with PIH.

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? A. Provide tactile stimulation. B. Administer flow by 100% oxygen. C. Asses the functionality of the monitoring device. D. Evaluate the newborn's color and respirations.

D. Monitors are an effective method for continual appraisal of a neonate's respirations, but a visual assessment of the infant oxygenation and respiratory status (D) should be implemented first. If the infant is not breathing, then tactile stimulation (A) should be given for no longer than 10 to 15 seconds before initiating CPR. Oxygen should be administered or increased (B) after determining the neonate's respiratory status. If there is normal color and presence of respirations after assessment, then possible causes of a false alarm (C) should be investigated for mechanical malfunction of the device.

An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? A. Further assessment is indicated. B. Petechiae occurs with forceps delivery. C. An increased blood volume causes broken blood vessels. D. The pinpoint spots are benign and disappear within 48 hours.

D. Rapid delivery and a tight nuchal cord cause the presenting parts (head) to have bruising and pin point hemorrhages (petechiae), which are benign and usually disappear within two days after birth (D). (A) is not indicated. Birth injuries caused by forceps (B) present as linear configuration across both sides of the face and outline the placement of the forceps. (C) is inaccurate.

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? A. Tactile stimulation. B. Commercial warm packs. C. Skin-to-skin contact with parent. D. Oral sucrose and nonnutritive sucking.

D. Studies of nonpharmacologic interventions for pain in the newborn most frequently indicate that the administration of oral sucrose and nonnutritive sucking (D), such as the provision of a pacifier, are effective in reducing objective indicators of pain after an invasive procedure. Other interventions, such as tactile stimulation (A) during apnea and bradycardic episodes and warm packs (B) for thermoregulation, have not been shown to reduce pain responses. Skin-to-skin contact (C) fosters neurobehavioral development and supporting parent-infant intimacy and attachment, but sucking behaviors provide the most effective pain-comfort responses

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement? A. Notify the client's healthcare provider. B. Bring the delivery table to the room. C. Prepare to administer an oxytocic. D. Document the findings in the client record.

D. This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record (D). There is no indication to notify the healthcare provider (A) or bring the delivery table into the room (B) at this time. Oxytocin augmentation (C) is not needed for this labor pattern.