MaAtt Final

Nurse practice Act

- sets the scope of practice - sets the standard of care - sets standards for education programs - grounds for disciplinary actions - sets licensure requirements - enforced by the state board of nursing - protects the patient - hospitals must follow the scope of practice. They can make them better, but can not go outside them.

A women has a family history of Tay-sachs and wants to know if her baby could be born with the disease. What is the earliest test that could be done to determine this? 1.CVS- 1st trimester 2.Amniocentesis- 2en trimester/chromosomal abnormalities and again for lungs(3rd trim) 3.MSAFP- for neural tube defects 4.Ultrasound

1. CVS - 1st trimester

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1. Type O negative

The nurse auscultates a fetal HR of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1.Inform the mother that the rate is normal 2.Reassess in 5 minutes to verify the results 3.Immediately report the rate to the HCP 4.Place the client on her left side and apply oxygen by face mask

1. inform the mother that the rate is normal

Which of the following findings would the nurse determine are presumptive/ subjective signs of pregnancy? Select all that apply. 1.Amenorrhea- haven't had a period 2.Breast tenderness 3.Quickening 4.Frequent urination 5.Uterine growth

1.Amenorrhea- haven't had a period 2.Breast tenderness 3.Quickening 4.Frequent urination

Family

2 or more people who live in the same household. They share common emotional bond and perform interrelated tasks - basic unit of society - come in many sizes, forms and represent racial, ethnical, cultural and socioeconomic diversity

A woman is in the transition phase of labor. Which of the follow comments should the nurse expect to hear? 1.I am so excited to be in labor 2.I can't stand this pain any longer 3.I need ice chips because I am so hot 4.I have to push the baby out right now.

2. I can't stand this pain any longer

A woman's temperature has just risen 0.4 degrees F and will remain elevated for the remainder of her cycle. What hormone is responsible for the temperature elevation? 1.Estrogen 2.Progesterone 3.LH 4.FSH

2. Progesterone

The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is high risk for infection and must be protected.

2. amniotic fluid may contain harmful viruses

A nurse is caring for four prenatal clients in the clinic. Which of the clients is high risk for placenta previa? 1. Jogger with low body mass index. 2. Smoker carrying fraternal triplets. 3. Registered professional nurse. 4. Police officer on foot patrol.

2. smoker carrying fraternal triplets

A G2P2002 client was examined 5 minutes ago. Her cervix was 8cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1.Offer the client the bedpan - if after exam she was still the same I could do this 2.Evaluate the progress of labor 3.Notify the physician 4.Encourage the client to push

2.Evaluate the progress of labor - does she need to poop or is the baby on the way

The nurse notes that a newborn who is 5 minutes old, exhibits the following characteristics: HR 108 BPM, RR 29 RPM with a lusty cry, pink body with bluish hands and feet, some flexion. What is the APGAR? a. 6 b. 7 c. 8 d. 9

3. 8

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. - Rooting 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. - Babinski 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends. - tonic

3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

A women, who is in labor, is in her hospital bed calmly talking to her husband. They are both excited the baby is on its way. What stage of labor would you expect this mother to be in. 1.Latent 2.Active 3.First 4.Second

3. first

A woman has just been admitted to the emergency department subsequent to a head-on automobile accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which of the following complications of pregnancy? 1. Placenta previa. 2. Transverse fetal lie. 3. Placental abruption. 4. Severe preeclampsia.

3. placental abruption

A mother who just delivered 24 hours ago notices a red rash with yellow pustules on her newborn's face and asks the nurse if she should be concerned. What would you tell the mother? 1.These spots are called stork bites and will disappear around the time your baby is 2 years old. 2.The pediatrician should see the rash as it could indicate infection 3.The rash is called erythema toxicum, and it is normal and should disappear within a week. 4.That is a port-wine stain and your baby will have it for the rest of its life.

3.The rash is called erythema toxicum, and it is normal and should disappear within a week.

The nurse places the FHR monitor and notes the HR is 74bpm. What is the first thing the nurse should do? 1.Inform the mother that the rate is normal 2.Immediately report the rate to the HCP 3.Place the client on her left side and apply oxygen by face mask 4.Assess the mother's heart rate

4. assess the mother's heart rate

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that more teaching is needed when the mother states that which of the following diseases is included in the screening test? 1. Hypothyroidism. 2. Sickle cell anemia. 3. Galactosemia. 4. Cerebral palsy

4. cerebral palsy

A woman has a history of toxic shock syndrome. She should be taught to avoid which of the following forms of birth control? A. Diaphragm. B. Intrauterine device. C. Birth control pills (estrogen-progestin combination). D. Depo-Provera (medroxyprogesterone acetate).

A. Diaphragm

A woman has a history of toxic shock syndrome. She should be taught to avoid which of the following forms of birth control? A. Diaphragm. B. Intrauterine device. C. Birth control pills (estrogen-progestin combination). D. Depo-Provera (medroxyprogesterone acetate).

A. Diaphragm

The nurse is assessing a pregnant client with type 1 DM about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes what statement? A. I will increase my insulin dosage for the first 3 months of pregnancy. Will actually decrease in 1st trimester B. My insulin dose will likely increase during the second and third trimesters. C. Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy. D. My insulin needs should return to normal w/in 7 - 10 days after birth if I'm bottle feeding.

A. I will increase my insulin dosage for the first 3 months of pregnancy. Will actually decrease in 1st trimester

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? A. Tachypnea and retractions B. Acrocyanosis and grunting C. Hypotension and bradycardia D. Presence of a barrel chest and acrocyanosis

A. Tachypnea and retractions

Habitual Abortion

Abortion occurs consecutively in 3 or more pregnancies

Fidelity

Agreement to keep promises

autonomy

Agreement to respect other's rights to self-determine a course of action; support independent decision making

Only 3 positive signs of pregnancy

Audible FHR, Palpable fetal movement, visualization on ultrasound

A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? A. Remind the mother that she will be able to have another baby in the future. B. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. C. Ask the woman if she would like the doctor to prescribe a sedative for her. D. Remove the baby from the delivery room as soon as possible.

B. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket.

The nurse is assessing a pregnant client in the second trimester with was admitted with suspected abruptio placentae. Which assessment finding would the nurse expect to note if the condition is present? A. Soft abdomen B. Uterine tenderness C. Absence of abdominal pain D. Painless, bright red vaginal bleeding

B. Uterine tenderness

Imminent Abortion

Bleeding and cramping increase. The internal cervical os dilates. Membranes may rupture.

A 19-year-old client with multiple sex partners is being counseled about the hepatitis B vaccination. During the counseling sessions, which of the following should the nurse advise the client to receive? A. The hepatitis B immune globulin before receiving the vaccine. B. A vaccine booster every 10 years. C. The complete series of three intramuscular injections. D. The vaccine as soon as she becomes 21.

C. The complete series of three intramuscular injections.

1. Which of the following is an indication to discontinue administration of magnesium sulfate in a woman with preeclampsia? a. Blood pressure of 120/70 b. Nausea and vomiting c. Epigastric pain d. Respiratory rate of 10

D. respiratory rate of 10

Naegle's Rule

Date of last LMP, subtract 3 months add 7 days

Variable Decelerations

Decrease of HR abruptly with no correlation with contractions Cord compression - NOT GOOD Mom in knee chest position, use sterile gloved hand to push on presenting part to relieve pressure on chord, stop pitocin, oxygen 8-10L, Call the OB

Justice

Fairness in care delivery and in use of resources

family of orientation

Family one is born into

McDonald's Rule

Fundal height from symphysis pubis 22cm - 34cm = weeks of gestation Fundus at symphysis pubis = 12 weeks gestation

GTPAL

G= # of TOTAL pregnancies T = number of total pregnancies that have reached 37 weeks or more P = number of total pregnancies that have reaches past 20-22 weeks A = number of abortions, miscarriages prior to 22 weeks L - number of living children - THIS IS THE ONLY ONE that accounts for multiples

paternalism

HCP makes a decision about a diagnosis, therapy or prognosis for the patient. Based upon the HCP belief about what is in the best interest of the patient they decide to reveal or withhold information

Late Deceleration

HR drops after contractions Indicates fetal hypoxia due to placental insufficiency Put mom on Left lateral side, stop Pitocin, oxygen 8-10L, IVF, Call OB

Early Decelerations

Mirror image Show head compression Just document, nothing needs to be done

Non-Stress Test

Mom is either in semifowlers or side lying Nothing is added to induce "stress" Mom pushes a button when she feels movement Reactive - reacted to movement with increased HR Baby moved and HR increased at least twice for 15bpm above baseline in 20 minutes GOOD Non-Reactive - HR did not increase with movement Not good, but not horrible, as baby could be sleeping They repeat this test, if still non-reactive they go to the contraction stress test

Do you have to have intercourse to get an STD?

No

Syphilis: Bacteria All pregnant women are tested

Stages of Disease: Primary - chancre x 4 weeks, weight loss, fever Secondary - contagious condyloma Latent - No signs or symptoms Tertiary - tumors Pregnancy Risk: Intrauterine growth restriction, preterm birth, stillborn Treatment: Early - penicillin G x 1, long duration - Penicillin IM once a week for 3 weeks

Contraction Stress Test

Stress is added - aka contractions to the uterus by Pitocin or nipple stimulation This is to see if the baby can handle vaginal birth Positive CST Decelerations were seen in HR NOT GOOD Negative CST No decelerations seen GOOD

Gonorrhea: Bacteria All pregnant women screened

Symptoms: 80% are asymptomatic, purulent greenish/yellow discharge, swelling/inflammation of vulva/cervix Pregnancy Risk: Newborn eye infection if exposed, risk of PID Treatment: Ceftriaxone/Rocephin 250 mg IM plus Azithromycin 1 gm PO, no intercourse for 7 days, treat partner, verify cure

Chlamydia: Bacteria (leading cause of infertility

Symptoms: Commonly asymptomatic, thin mucopurulent discharge, burning and frequency, lower abdominal pain Test: NAAT Pregnancy Risk: Newborn eye infection, PID-blocked fallopian tubes resulting in ectopic pregnancy, infertility Treatment: Azithromycin or Doxycycline, no intercourse for 7 days, treat partners, repeat test after 3 weeks to confirm cure

Herpes simplex virus: recurrent life-long disease

Symptoms: Painful blisters/vesicles, flu-like symptoms, unpredictable recurrence Pregnancy Risk: newborn infected Treatment: no cure, acyclovir/Valacyclovair PO as suppression in third trimester

Trichmoniasis Parasite

Symptoms: Possible asymptomatic, yellow/green frothy malodorous discharge, pain during intercourse, strawberry red marks on cervix Pregnancy Risk: PROM, preterm labor Treatment: Flagyl, treat partners

HPV

Symptoms: soft grayish cauliflower-like lesions (genital warts), may cause itching, be friable (bleed), painful Pregnancy Risk: cervical cancer Treatment: no single treatment, podofilex solution, cryotherapy, gardisil vaccine 3 doses

Bacterial Vaginosis

Symptoms: watery gray discharge, possible fishy odor Test: Clue cells seen on wet mount Pregnancy Risk: PROM, Preterm labor, infection Treatment: Flagyl or Clindamycin, avoid sex

Missed abortion

The fetus dies in utero but is not expelled. Uterine growth ceases, breast changes regress, and the woman may report brownish vaginal discharge. The cervix is closed. If the fetus is retained beyond 4 233k s fetal autolysis results in the release of thromboplastin and DIC may develop

VEAL CHOP

Variable Deceleration = Cord Compression Early Deceleration = Head Compression Acceleration = Okay (Oxygenated) Late Acceleration = Placental Insufficiency

bi-nuclear family

a post-divorce family in which the biological children are members of two nuclear households

1. A sterile vaginal exam is contraindicated in: a. A patient with placenta previa b. A patient who is GBS+ (Group B Strep) c. A patient with ruptured membranes d. A patient in transition

a. A patient with placenta previa

1. The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? a. Chest circumference 31.5 cm, head circumference 33.5 cm b. Chest circumference 30 cm, head circumference 29 cm c. Chest circumference 38 cm, head circumference 31.5 cm d. Chest circumference 32.5 cm, head circumference 36 cm

a. Chest circumference 31.5 cm, head circumference 33.5 cm

1. A 26-week gestation woman id diagnosed with severe preeclampsia. The nurse assesses for which of the following signs/ symptoms associated with HELLP syndrome? a. Epigastric pain b. High serum protein c. Hyporeflexia d. Thrombocytopenia e. Bloody stools

a. Epigastric Pain d. Thrombocytopenia

1. Transitional physiology involves a change in the circulation pattern at birth. The placenta blood flow ceases and the lungs become the organ of gas exchange. Which of the following occur as part of this transition: a. The lungs expand b. Surfactant decreases lung compliance c. The ductus arteriosus and the foramen ovale remain open to facilitate circulation. d. The systemic vascular resistance decreases e. Pulmonary vascular resistance decreases

a. The lungs expand e. Pulmonary vascular resistance decreases

A 2-day old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 2.5% of the birth weight. Which of the following nursing actions is appropriate? a. Do nothing because this is normal weight loss b. Notify the neonatologist of the significant weight loss c. Advise the mother to bottle feed the baby at the next feed d. Assess the baby for hypoglycemia with a glucose monitor

a. do nothing because this is normal weight loss

Which of the following best describes the clinical signs/symptoms of chlamydial infection in women? a. most women are asymptomatic b. most women complain of discharge c. most women complain of pelvic pain d. most women complain of urinary symptoms

a. most women are asymptomatic

1. The nurse is caring for 4 newborns, who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? The infant's mother had: a. Ruptured membranes for 36 hours b. An IV of Lactated Ringer's solution c. A labor that lasted 12 hours d. A cesarean birth with her last child

a. ruptured membranes for 36 hours

1. A client is admitted to the hospital with an ectopic pregnancy. The symptoms that caused her to seek health care is most likely to have been: a. Sharp unilateral abdominal pain b. Uncontrolled vomiting c. Lack of fetal movement d. Profuse vaginal bleeding

a. sharp unilateral abdominal pain

Complete Abortion

all the products of conception are expelled. The uterus is contracted and the cervical os maybe closed.

non-maleficence

avoidance of causing harm or hurt to others

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles could the nurse safely choose for the injection? a. 5/8 inch, 18 gauge b. 5/8 inch, 25 gauge c. 3.1 inch, 18 gauge d. 4.1 inch, 25 gauge

b. 5/8 inch, 25 gauge

A client is 40 minutes postpartum from a forceps (causes trauma) delivery of a 4500 gram (large baby) neonate over a right mediolateral episiotomy (bleeding). The client is at risk for each of the follow nursing diagnoses. Which of the diagnoses is highest priority at this time? a. Ineffective breast feeding b. Fluid Volume Deficit c. Infection d. Pain

b. Fluid Volume Deficit- risk for hemorrhage - most life threatening- at least 3 risk factors: forceps, large baby, episiotomy.

1. An increased risk for shoulder dystocia is associated with: a. Preterm labor b. Maternal diabetes c. VBAC d. Previous precipitous birth

b. Maternal Diabetes

1. A baby is entering the pelvis in the vertex presentation with the posterior frontanel palpable near the mother's sacrum. The nurse determines that which of the following malpositions is consistent with this situation? a. LSP (left sacral posterior) b. ROP (right occiput posterior) c. LMA (left mentum anterior) d. RADA (right acromion dorsal anterior)

b. ROP (right occiput posterior)

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? a. apply an antibiotic ointment to the perineum daily b. change the peripad at each voiding c. void at least every 2 hours d. spray the perineum with a povidone-iodine solution after toileting

b. change the peripad at each voiding

1. When a breech presentation is suspected during the intrapartum period, a priority nursing interventions is to diligently observe the client for signs of: a. Hip dysplasia b. Cord prolapse c. A precipitous delivery d. Labor progression

b. cord prolapse

1. When caring for a newborn, the nurse must be alert for what potential sign of cold stress? a. Decreased activity level - newborns are unable to shiver as a means of heat production, they increase their activity level instead. b. Increased respiratory rate c. Appears to stop breathing for 5-10 sec while asleep d. Hyperglycemia - hypoglycemia would occur with cold stress

b. increased respiratory rate

1. A 28-year-old, G3G2 has just been diagnosed with gestational diabetes at 30 weeks. The client asks what types of complications may occur with this diagnosis. Which complications should the nurse identify as being associated with gestational diabetes? a. Maternal seizures b. Large for gestational age infant c. Hyperglycemia in the newborn d. Hypoglycemia in the newborn e. Fetal anemia

b. large for gestational age d. hypoglycemia in the newborn

The maternity nurse is preparing for the admission of a client in the 3rd trimester who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. Which prescription should the nurse question? A. Ultrasound B. Manual pelvic exam C. H&H blood sample D. FHR monitoring

b. manual pelvic exam

The risk of perinatal transmission of HIV can be reduced with antiretroviral treatment. Identification in the preconception period is essential. Which of the following statements about HIV screening in pregnancy is most accurate? Pregnant women: a. Are routinely screened for HIV with all prenatal lab testing b. Must be given the option to opt out of routine HIV testing c. Must provide written consent for HIV screening d. Should be offered HIV screening in each trimester

b. must be given the option to opt out of routine HIV testing

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm fungus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? a. massage the fundus b. notify the obstetrician c. administer oxytocin d. assist the client to the bathroom

b. notify the obstetrician

A woman has been diagnosed with primary syphilis. Which of the following physical findings would the nurse expect to see? a. Cluster of vesicles b. Pain-free lesion c. Macular rash d. Foul-smelling discharge

b. pain-free lesion

A woman has been diagnosed with primary syphilis. Which of the following physical findings would the nurse expect to see? a. Cluster of vesicles b. Pain-free lesion c. Macular rash - secondary along with lesions d. Foul-smelling discharge

b. pain-free lesions

1. A 34 year old with chronic hypertension arrives at the emergency department stating that she is in labor and complaining of constant pain between contractions. The nurse palpates a rigid abdomen with no signs of relaxation and concludes that the: a. fetus birth may be imminent b. patient may have abruptio placentae c. patient may have placenta previa d. fetus may be in the breech presentation

b. patient may have abruptio placentae

A newly diagnosed insulin dependent diabetic, with good blood sugar control at 20 weeks gestation, asks how her diabetes will affect her baby. The best explanation would include: A. Your baby may be smaller than average at birth. - if uncontrolled blood sugar B. Your baby may be larger than average at birth. C. As long as you control your blood sugar, your baby won't be affected D. Your baby might have high blood sugar for several days - would be opposite

b. your baby may be larger than average at birth

1. A Client is being discharged from the hospital after evacuation of a molar pregnancy. The nurse recognizes that additional discharge teaching is required when the client states: a. "I am so sad for my loss" b. "I may need to have chemotherapy after this" c. "I will need to see the doctor in one year for a follow-up" d. "I will use contraception for the next year"

c. "I will need to see the doctor in one year for a follow-up"

1. A primigradida with pregesational type 1 diabetes is at her first prenatal visit. When discussing changes in insulin needs during pregnancy and birth, the nurse explains that based on her blood glucose levels she should expect to decrease her insulin dosage between the: a. 8th and 11th weeks of gestation b. 18th and 21st weeks of gestation c. 24th and 28th weeks of gestation d. 36th week of gestation and the time of labor

c. 24th and 28th week of gestation

1. One minute after birth a baby girl was assessed to be crying strongly in a flexed position. Her heart rate was 110, and her body was pink with bluish hands and feet, She cried vigorously and turned away when her nares were suctioned. The nurse assigs an Apgar score of: a. 7 b. 8 c. 9 d. 10

c. 9

1. The nurse known that in some cases, breastfeeding is not advisable. Which mother should counseled against breastfeeding? a. A mother with a poorly balanced diet b. A mother who is overweight c. A mother who is HIV positive d. A mother who has twins

c. A mother who is HIV positive

1. A patient who is having a difficult labor is diagnosed with cephalopelvic disproportion (CPD). The nurse should question which medical order: a. Maintain NPO status b. Start IV of Normal Saline c. Add 10 units of oxytocin to IV fluids - cesarean birth is indicated when there is a cephalopelvic disproportion, no need to induce labor may result in uterine rupture and fetal compromise d. Record fetal heart tones every 15 minutes

c. Add 10 units of oxytocin to IV fluids - cesarean birth is indicated when there is a cephalopelvic disproportion, no need to induce labor may result in uterine rupture and fetal compromise

1. When caring for the newborn after a vaginal delivery, the nurse needs to be able to identify the respiratory changes that occur during the transition of the fetus to extrauterine life. Which factors contribute to the baby transitioning from a fluid filled environment to breathing independently after birth? a. An increase in circulating prostaglandin levels b. Marked deceases in pulmonary circulation c. Inspiratory gasp triggered by the elevation in PCO2 and decreases in pH and PO2 d. Stimulation of skin nerve endings due to chilling e. Chemical stimulator associated with transient asphyxia of the fetus

c. Inspiratory gasp triggered by the elevation in PCO2 and decreases in pH and PO2 d. Stimulation of skin nerve endings due to chilling e. Chemical stimulator associated with transient asphyxia of the fetus

1. During an assessment of a 12 hour old newborn the nurse notices pale pink spots on eyelids and forehead. The nurse documents this finding as: a. Nevus vasculosus - (strawberry mark) is a capillary hemangioma. b. Nevus flammeus - (port-wine stain) a capillary angioma, located directly below the epidermis c. Telangiectatic nevi d. A Mongolian spot- black pigmentation on the dorsal area of the buttocks

c. Telangiectatic nevi - (stork bites) are pale pink or red spots that appear on the eyelids, nose, lower occipital bone, or the nape of the neck.

1. A patient is admitted in active labor with her second baby. Her prenatal record indicates she has a history of genital herpes. When performing the admission assessment, the nurse notes herpetic lesions on the genitalia confirmed by the physician, in order to shorten the second stage of labor: a. Done vaginally, with forceps and an episiotomy, to shorten the second stage of labor b. Preceded by 2 doses of antibiotics, to decrease transmission to the baby c. A cesarean birth, to prevent exposure of the baby to herpetic lesions d. A cesarean birth, to decrease maternal stress from the labor and minimize exacerbation of the herpes.

c. a cesarean birth, to prevent exposure of the baby to herpetic lesions

1. The student nurse notices that the newborn has the ability to ignore the constant crying of the other newborns in the newborn nursery. The nursing instructor explains that this newborn behavior is known as: a. Self-quieting behavior b. Orientation c. Habituation d. Active-alert state

c. habituation

1. A Moro reflex is the single best assessment of the neurologic ability in a newborn. Unit protocols should specify what action for eliciting a Moro reflex? a. Turn her onto her abdomen and see if she can turn her head. b. Stroke the sole of the foot and look for the toes to fan out c. Lift her head while she is supine and allow it to fall back 1 inch d. Vigorously shake the newborns bassinette until she responds by flaring her arms out.

c. lift her head while she is supine and allow it to fall back 1 inch

1. Following delivery, the nurse would first assess which 2 newborn body systems that must undergo the most rapid changes to support extrauterine life? a. Gastrointestinal and hepatic b. Neurologic and temperature control c. Respiratory and cardiovascular d. Hematologic and cardiovascular

c. respiratory and cardiovascular

1. Which of the following findings on a newborn nursing assessment would warrant a call to the newborn's pediatrician? a. /newborn's breast tissue slightly engorged b. Heart rate of 180 bpm c. Respiratory rate of 75 bpm d. Presence of milia on the nose

c. respiratory rate of 75 BPM - ABC's have priority

Mucocutaneous lesions and rash are most commonly seen during which stage of syphilis? a. latent b. primary c. secondary d. tertiary

c. secondary

1. The nurse anticipates that a newborn male, estimated to be 39 weeks gestation, would exhibit which characteristic? a. The ability to move his elbow past the sternum- would not have the ability to move elbow past midline b. Extended posture at rest- good muscle tone will result in a more flexed posture when at rest c. Testes descended into the scrotum- full tern infant will have both testes in his scrotum and rugae on his scrotum d. Abundant lanugo over his entire body - only moderate amount of lanugo, usually on his shoulder and back

c. testes descended into the scrotum

nuclear family

children live with both parents

What is the most common reportable STD in the US

chlamydia

A 26-week gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following s/s? A. Low serum creatinine B. High serum protein C. Bloody stools D. Epigastric pain

d. epigastric pain

The nurse is educating a group of adolescent women regarding STIs. The nurse knows that learning was achieved when a group member states that the most common sign/symptom of STIs is which of the following? a. Menstrual cramping b. Heavy menstrual periods c. Flu-like symptoms d. Lack of signs or symptoms

d. lack of signs or symptoms

1. A client who is 3 months pregnant comes to the prenatal clinic because she is having some dark brown vaginal bleeding and experiencing severe nausea and vomiting. Her fundal height is larger than expected, there are no fetal heart tones auscultated. Which of the following complications should the nurse suspect? a. Hyperemesis gravidarum b. Threatened abortion c. Placenta previa d. Molar pregnancy

d. molar pregnancy

A pregnant client has mild preeclampsia, which assessment finding indicates worsening preeclampsia and the need to notify the physician? A. Increased urinary output B. Dependent edema has resolved C. BP is at the prenatal baseline D. Patient complains of headache and blurred vision

d. patient complains of headache and blurred vision

A 14-year-old girl and her mother go to her yearly checkup at the pediatrician's office. The nurse wants to offer a new vaccine against the human papilloma virus. Why is it important for the client to receive this vaccine? a. The human papilloma virus is spread through casual contact in schools. b. There is only one type of human papilloma virus that infects the genital tract. c. The human papilloma virus is found exclusively in genital warts. d. The human papilloma virus is associated with cervical dysplasia and cancer.

d. the human papilloma virus is associated with cervical dysplasia and cancer

family of procreation

family one establishes

Incomplete Abortion

part of the products of conception are retained, most often the placenta. The internal os is dilated

Veracity

refers to truth telling

Beneficence

taking positive action to help others

Threatened abortion

unexplained bleeding, cramping, or backache indicate that the fetus may be in jeopardy. Bleeding may persist for days. The cervix is closed. Maybe followed by partial or complete expulsion of pregnancy, or it may resolve without threatening the fetus.