Midterm/Misc.

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement?

"Antibodies are not usually formed until after exposure to an antigen."

A nursing instructor is teaching students about hospice care and realizes further instruction is needed when a student makes which statement?

"Hospice care is for children only."

A 2-day postpartum client tells the nurse that she is experiencing abdominal cramps whenever she breastfeeds her baby. Which of the following is the most appropriate response from the nurse?

"Oxytocin is released when the baby sucks, which causes the uterus to contract."

A nurse is conducting an assessment of a family. Which question would be most appropriate for the nurse to use when obtaining information about the family's structure and function?

"Who is the primary decision maker in the household?"

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which of the following rates would cause the nurse to intervene?

60-79 beats per minute

When should a client who's Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization?

At about 28 weeks' gestation and again within 72 hours after birth

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse?

Instruct the client to go to an emergency room for an urgent assessment.

A nurse working in the emergency department who suspects child abuse should do which of the following?

Report it to the authorities.

A female patient had a diagnostic laparoscopy and is now reporting a sharp pain in her shoulder. What response is a priority by the nurse?

Some of the carbon dioxide that was used to insufflate the abdomen has likely escaped under the diaphragm and this will resolve on its own.

Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice?

VBAC may be possible if the client has not had a classic uterine incision.

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?

absence of any seizure activity during the first 48 hours

A client is being prepared for artificial insemination. Which finding is the most suggestive to determine if the client is ovulating?

change in the cervical mucus

Which factor is most critical to effective home care?

commitment to home care from family and other essential people

While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her primary health care provider (HCP) immediately if the client experiences which symptom?

dyspnea at rest

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

orange juice

A nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:

results from exposure of an antigen through immunization or disease contact.

A nurse is discharging a young patient who has been hospitalized for the last 3 weeks with leukemia. The patient will need home care. When starting the discharge instructions, the nurse focuses on the mother. The father informs the nurse that he will be the one caring for the child. In this case the nurse made an assumption regarding which of the following?

role fulfillment

A client who is 37 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting, the nurse might ask which question?

"What changes have you made at home to get ready for the baby?"

A nurse suspects that a 6-year-old girl is being sexually maltreated by her father, based on some comments made by the girl. Which of the following methods would be most effective in confirming the nurse's suspicion?

Ask the girl to draw a picture of what happened

A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. Which of the following activities should the nurse immediately perform?

Begin continuous fetal heart rate monitoring.

CRASH

Can be used to help with cultural competence. C- culture; R-respect; A-assess differences; S-sensitivity; H-humanity

A client asks the nurse, "What would be the best way to get pregnant." The nurse would incorporate which of the following in the response?

Conception is more likely when intercourse occurs within 72 hours of ovulation

The nurse sees a client in the postpartum clinic for a checkup related to a recent mastitis infection. The nurse wishes to assess how the client is managing the infant's needs and to do a breastfeeding assessment. The client informs the nurse that she is finishing her prescribed cloxacillin in a few days. What is the nurse's most appropriate response to the client about mastitis? Select all that apply.

Encourage your infant to feed from the infected breast first." "You need to continue to breastfeed, and the antibiotics will protect your baby from infection." "Allowing your infant to nurse is more therapeutic than pumping."

A 2-year-old child has been diagnosed recently with leukemia. She has been admitted to the hospital for initiation of treatment. The family is trying to cope with the new diagnosis, and family members describe themselves as being "in a state of shock." In working with the family, which of the following would be the priority nursing diagnosis?

Ineffective family coping related to new illness of the child

Which statement is not an advantage of home care?

It can increase self-confidence because it allows sick people to rest while others take care of them

A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time?

Pregnancy loss

A nurse is assessing a family and asks, "On whom does the family depend to provide the solution to problems?" What role is the nurse trying to establish?

Problem-solver

Nursing roles: Intimate partner violence

Provide information on where to go and a plan if the person decides to leave. Ensure the abused that the abuse is not their fault. DO NOT ask why, talk negatively about the abuser, ask questions in front of the abuser or talk to the abuser about the situation. The goal is to empower the victim without making the abuse worse. It is ok to say to the victim that you believe the abuse will only get worse, they are not at fault, etc. ALL women should be assessed for IPV. There are some mandated reporting rules but you have to inform the abused person before they tell you that you are a mandated reporter.

Which are included in child maltreatment? Select the best answer.

Psychological, physical, and sexual maltreatment and neglect

Cultural Competency

Respect customs, culture, and the values of all, even those different than our own. It is important to assess the patient's cultural aspects. Communication, Space, Orientation to time, Family roles.

Genogram

Shows a family tree and includes work and health history of relatives and whether or not they are living or deceased. Can help identify what a person may be at risk for. Can show some economic status.

Ecomap

Shows the relationship of the family within the community. Who can they depend on? What are their ties? What organizations do they belong to?

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do?

Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed.

Cycle of violence

Tension building, incident, honeymoon phase.

Couples who engage in coitus daily, hoping to cause early impregnation, may actually have more difficulty conceiving than those who space coitus to every other day.

True

The first phase of divorce is marked by quarreling, hurt feelings, and whispered conversations, as the parents realize they are no longer compatible.

True

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area.

Intimate partner violence

Violence of any kind between a person and their significant other. Pregnant women are at high risk for this and often this is when the abuse starts.

Which statement is false regarding screening for intimate partner violence in women?

Women tend to fit a profile of abuse, and victims tend to share similar physical characteristics.

A couple has recently been divorced. The couple has joint custody of their 15-year-old daughter. The nurse recognizes that the daughter is now at a 50% greater risk for:

beginning smoking or drinking alcohol.

A pregnant teen at 32 weeks' gestation is receiving home care because of elevated blood pressure. She has been prescribed bed rest and a low-sodium diet. Because this is the client's first pregnancy, what other information is a priority that the nurse should include in her teaching?

birth education

A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for:

changes in cervical effacement and dilation after 1 to 2 hours

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?

hold her breath throughout the length of the contraction

A preceptor overhears one nursing student tell another that she is going with the preceptor on a home visit and is excited to talk to the mother who will likely be the child patient's caregiver. What assumption did the student make?

identity of caregiver

Parents who bring a 3-week-old neonate to the hospital report that he's been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm:

pyloric stenosis.

A couple comes to the clinic and states to the nurse, "I don't think we are ever going to be able to have children. We have been trying but have had no luck." What assessments does the nurse anticipate will be performed for this couple? Select all that apply.

semen analysis ovulation monitoring tubal patency