NCLEX Practice 2

The client is instructing a client recovering from a classic uterine incision for a cesarean birth. Which statement indicates that the client understands implications for future pregnancies that are secondary to this type of incision? 1. "I can only have one more baby." 2. "The next time I have a baby, I can try to deliver vaginally." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "The risk of rupturing my uterus is too high for me to have any more babies."

Answer: 3 Explanation: 1. Future pregnancies are not limited to one. 2. Attempting a vaginal birth is contraindicated, and future births will be planned cesareans. *3. A classic uterine incision is made in the upper uterine segment and holds an increased risk of rupture in subsequent pregnancy, labor, and birth.* 4. Future pregnancies are not prohibited.

A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time? 1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4. Assist the client to squat during the second stage.

Answer: 4 Explanation: 1. A client with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean section. This client should either be given only clear liquids or be NPO to reduce the risk of aspiration should a cesarean section need to be performed. 2. The cervix is normally assessed when the client's labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a client was in the active phase of labor and cephalopelvic disproportion was a risk. Every 8 hours is too far apart. 3. Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority. 4. Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.

What should the nurse anticipate the labor pattern for a fetal occiput posterior position to be? 1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4. Prolonged with regard to the overall length of labor

Answer: 4 Explanation: 1. Overall labor is often prolonged, not precipitous. 2. Overall labor is often prolonged, not more rapid. 3. Overall labor is often prolonged, not shorter. 4. The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor.

After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing? 1. Infection 2. Placenta accreta 3. Hypertensive crisis 4. Amniotic fluid embolus

Answer: 4 Explanation: 1. These are not manifestations of an infection. 2. Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium. The major complications of placenta accreta include maternal hemorrhage and failure of the placenta to separate following birth of the infant. 3. The client is hypotensive. 4. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.

6) A newly diagnosed type 1, insulin-dependent diabetic with good blood sugar control at 20 weeks' gestation asks how the diabetes will affect the baby. How should the nurse respond? 1. "Your baby may be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3 "Your baby might have high blood sugar for several days." 4. "As long as you control your blood sugar, your baby will not be affected at all."

2. The infant of a diabetic mother produces excessive amounts of insulin in response to the high blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because the infant utilizes the glucose in the bloodstream.

A client at 40 weeks' gestation is prescribed dinoprostone (Cervidil) for cervical ripening. What should the nurse include when teaching the client about this medication? Select all that apply. 1. Cramping can occur. 2. Uterine irritability is expected. 3. Membrane rupture is a sign of labor. 4. Leakage of the gel should be reported. 5. Strong regular contractions are expected

Answer: 1, 2, 3 Explanation: *1. Cramping is a common reaction to the medication.* *2. Uterine irritability is a common reaction to the medication.* *3. Membrane rupture is a sign of labor and not a reaction to the medication.* 4. Leakage of the gel is a common reaction that does not need to be reported. 5. Strong regular contractions are a sign of labor and not a reaction to the medication.

A primiparous client is at 42 weeks' gestation. What order should the nurse question? 1. Begin non-stress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4. Schedule labor induction for tomorrow.

Answer: 2 Explanation: 1. The non-stress test is a commonly used assessment for the postterm fetus. 2. A postterm pregnancy is high risk. Fetal assessments must be obtained to verify fetal well-being or the need for delivery via induction or cesarean. One week is too long a time period between assessments. 3. A biophysical profile is a commonly used assessment for the postterm fetus. 4. Labor induction is likely to occur with postterm pregnancies because the aging placenta becomes less efficient at transporting oxygen and nutrients and because the risk of fetal macrosomia increases with length of gestation.

8) A 31-year-old woman who is at high risk for diabetes is at 18 weeks' gestation. During her first antenatal visit, which is the accurate approach to evaluate the client for diabetes? 1. Conduct screening for type 2 diabetes mellitus as soon as possible. 2. Begin serial testing of the client's serum glucose and HA1c at 24 weeks' gestation. 3. If diabetes is diagnosed, consider this condition to be gestational diabetes mellitus (GDM). 4. Recognize HA1c equal to or greater than 4.5% or a fasting plasma glucose level equal to or greater than 90 mg/dL as being diagnostic of diabetes.

1. Women at high risk for type 2 DM should be screened for diabetes as soon as possible. Page Ref: 269

Answer: 1, 2, 3 Explanation: 1. The exact cause of hydramnios is unknown. 2. Hydramnios can cause maternal shortness of breath and edema. 3. Hydramnios is associated with maternal diabetes. 4. Hydramnios is not associated with large-for-gestational-age infants. 5. Renal malformation or dysfunction and postmaturity can cause oligohydramnios.

13) A pregnant client diagnosed with hydramnios asks for more information about this health problem. What should the nurse include in this teaching? Select all that apply. 1. The exact cause is unknown. 2. It can cause shortness of breath and edema. 3. It can be associated with maternal diabetes. 4. It occurs in large-for-gestational-age infants. 5. It is associated with renal malformation or dysfunction.

Answer: 1, 2, 3, 4 Explanation: 1. As soon as the fetus is term, induction is typically scheduled because the fetus is at an increased risk for intrauterine fetal demise. 2. Decreased amniotic fluid can contribute to fetal head compression, which can manifest itself as early decelerations. 3. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. 4. Less amniotic fluid lessens the cushioning effect, and cord compression is more likely. 5. Labor progress is slower than average due to the decreased fluid volume.

14) When caring for a client with oligohydramnios, on what should the nurse focus? Select all that apply. 1. Induction is typically scheduled. 2. Early decelerations are more likely. 3. Fetal pulmonary hypoplasia can develop. 4. There is an increased risk of cord compression. 5. Labor progress is often more rapid than average.

Answer: 4 Explanation: 1. Hydramnios is not suspected simply by virtue of a twin gestation. 2. A quadruple screen is not used to determine hydramnios. 3. Hydramnios occurs when there is more amniotic fluid than normal for gestation. 4. The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation.

15) For which reason should the nurse suspect hydramnios in a pregnant client? 1. The client is pregnant with twins. 2. The quadruple screen comes back positive. 3. There is less amniotic fluid than normal for gestation. 4. The fundal height increases disproportionately to the gestation.

Answer: 2, 3, 5 Explanation: 1. Flushing is a maternal adverse effect of magnesium sulfate. 2. Fetal side effects of magnesium sulfate may include lethargy that persists for 1 or 2 days following birth. 3. Fetal side effects of magnesium sulfate may include hypotonia that persists for 1 or 2 days following birth. 4. Poor sucking reflex is not an adverse effect of magnesium sulfate. 5. Respiratory depression in the newborn can also occur after maternal magnesium sulfate.

17) The nurse is caring for the newborn of a client who received magnesium sulfate for preterm labor. Which fetal effects should the nurse attribute to the client's medication treatment? Select all that apply. 1. Flushing 2. Lethargy 3. Hypotonia 4. Poor sucking reflex 5. Respiratory depression

14) A client who is 32 weeks pregnant is HIV positive, but asymptomatic. What would be important in managing her pregnancy and delivery? 1. An amniocentesis at 30 and 36 weeks 2. Weekly non-stress testing beginning at 32 weeks' gestation 3. Administration of intravenous antibiotics during labor and delivery 4. Application of a fetal scalp electrode as soon as her membranes rupture in labor

2. Clients who are HIV positive are considered high-risk pregnancies. Therefore, beginning at about 32 weeks, these clients have weekly non-stress tests to assess for placental function and an ultrasound every 2 to 3 weeks to assess for intrauterine growth retardation (IUGR). Page Ref: 282

10) A woman at 30 weeks' gestation and a history of sickle cell anemia is experiencing fever, chills, and diarrhea for 3 days. What are the most serious potential complications that this client faces? 1. Severe lethargy 2. Sickle cell crisis 3. Electrolyte imbalance 4. Fetal neural tube defects

2. Dehydration and fever can trigger sickling and crisis; for this reason, maternal infections are treated promptly. Page Ref: 276

3) The nurse suspects that a pregnant client is a substance user. Which approach should the nurse take during the health history? 1. Explaining how harmful drugs can be for her baby. 2. Asking the woman directly, "Do you use any street drugs?" 3. Asking the woman if she would like to talk to a counselor. 4. Asking some questions about over-the-counter medications and avoiding the mention of illicit drugs.

2. The best method of finding out if a client is using substances is to be direct and ask the question in a direct fashion without prejudice, bias, or negative body language. Lack of judgmental attitudes/body language typically results in honest answers. Page Ref: 279

Answer: 3 Explanation: 1. Grade 1 abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority. 2. Late decelerations are an abnormal finding, but put only the fetus at risk. This client is not the highest priority. 3. Bleeding with a placenta previa is a complication that can be life threatening to both the mother and baby. This client is the highest priority. 4. Although pregnancy-induced hypertension increases the risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority.

4) The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first? 1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push 2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 4. 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously

Answer: 4, 5 Explanation: 1. Multiparity does not cause the same release of thromboplastin that triggers DIC. 2. Preterm labor does not cause the same release of thromboplastin that triggers DIC. 3. Diabetes does not cause the same release of thromboplastin that triggers DIC. 4. Abruptio placentae leaves intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. 5. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC.

5) The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. What risk factors should the nurse include about this health problem? Select all that apply. 1. Multiparity 2. Preterm labor 3. Diabetes mellitus 4. Abruptio placentae 5. Prolonged retention of a fetus after demise

Answer: 4 Explanation: 1. Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or prn. 2. Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor. 3. Vaginal examinations are contraindicated because the examination can stimulate bleeding. 4. Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety.

6) A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client? 1. Assessing blood pressure every 2 hours 2. Evaluating the fetal heart rate with an internal monitor 3. Limiting vaginal examinations to only one per 24-hour period 4. Monitoring for blood loss, pain, and uterine contractibility

Answer: 1, 3, 4 Explanation: 1. Abruptio placentae can cause anxiety for both the client and fetus. 2. There is no information regarding the gestational age of this client. The fetus may not be premature. 3. Maternal mortality and perinatal fetal mortality are concerns due to blood loss. 4. Maternal mortality and perinatal fetal mortality are concerns due to hypoxia. 5. Abruptio placentae is a premature separation of the placenta, not a genetic abnormality

7) A multigravida client with suspected abruptio placentae is admitted in active labor. Which nursing diagnoses should the nurse identify as appropriate for this client? Select all that apply. 1. Anxiety related to concern for own safety 2. Ineffective Coping related to premature birth 3. Fluid Volume, Risk for Deficit, related to hypovolemia 4. Tissue Perfusion, Risk for Altered, related to blood loss 5. Knowledge Deficit related to lack of information about inherited genetic defects

Answer: 3 Explanation: 1. This describes a marginal placenta separation, grade 1. 2. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues. 3. With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding. 4. This describes a marginal placenta separation, grade 1.

8) A pregnant client is diagnosed with central abruptio placentae. What can the nurse infer about the client's condition? 1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding. 2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage. 3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding. 4. Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding.

Answer: 3 Explanation: 1. Preeclampsia is not diagnosed until the 20th week of gestation. This client is only at 18 weeks. Further, blood pressure can be assessed in either arm when the client is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm. 2. Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time. 3. A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth. 4. Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those that are spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.

9) The home health nurse is visiting the home of a client who is 18 weeks pregnant with twins. Which nursing action is most important? 1. Assess the client's blood pressure in the upper right arm. 2. Collect a cervicovaginal fetal fibronectin (fFN) specimen. 3. Teach the client about foods that are good sources of protein. 4. Determine whether the pregnancy is a result of infertility treatment.

The nurse is supervising care in the emergency department. Which situation requires immediate intervention? 1. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20. 2. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports the presence of fetal movement. 3. Spotting of pinkish brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour. 4. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer solution running at 125 mL/hour.

Answer: 1 Explanation: 1. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this situation. Since there is no information given that the client has an IV started, this client is the least stable, and therefore the highest priority. 2. Occasional spotting can occur. The presence of normal vital signs and usual fetal movements reduces this client's risk of needing immediate intervention. 3. Bleeding in the first trimester can be indicative of the beginning of spontaneous abortion or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring and will determine care. Because this client is very early in the pregnancy and only experiencing spotting, it is not appropriate to have an IV at this time. 4. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the client's vascular volume.

The nurse is admitting a client at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask? 1. "Do you have a safe place where you can go?" 2. "What did you do to make your spouse so angry?" 3. "How many times has this happened in the past?" 4. "Will you be pressing charges against your spouse?"

Answer: 1 Explanation: 1. This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of a repeated attack and further injury to both mother and fetus. 2. This statement is blaming and must be avoided to establish a trusting, therapeutic relationship with an abused client. 3. Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority. 4. Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more importance.

The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4. 30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz

Answer: 1 Explanation: 1. Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern. 2. Hypertension does not impact labor pattern; this client has no risk factors for either hypertonic or hypotonic labor pattern development. 3. Although this client is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this client has no risk factors for an abnormal labor pattern. 4. This client has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development.

The nurse is reviewing the medical history of a pregnant client being considered for cervical ripening. Which data indicate that the order for misoprostol (Cytotec) should be reconsidered? Select all that apply. 1. Current fetal heart rate is tachycardic. 2. Client had one cesarean live birth 3 years ago. 3. Uterine contractions are occurring every 2 minutes. 4. Client has 2+ pedal edema and elevated blood pressure. 5. There is a history of placenta previa with one previous pregnancy.

Answer: 1, 2, 3 Explanation: *1. Absolute contraindications for the use of misoprostol include fetal tachycardia.* *2. Absolute contraindications for the use of misoprostol include a history of previous cesarean birth.* *3. Absolute contraindications for the use of misoprostol include the presence of uterine contractions 3 times in 10 minutes.* 4. Evidence of maternal preeclampsia or eclampsia is not an absolute contraindication for the use of misoprostol. 5. Absolute contraindications for the use of misoprostol include the presence of placenta previa, not a history of placenta previa with a previous pregnancy.

A client is recovering from general anesthesia after an emergency cesarean birth. What actions should the nurse take when providing care to this client? Select all that apply. 1. Position on the left side. 2. Observe urine for hematuria. 3. Assess level of anesthesia every 15 minutes. 4. Evaluate perineal pad every 15 minutes for 1 hour. 5. Gently palpate the fundus with vital signs assessment.

Answer: 1, 2, 4, 5 Explanation: *1. If the client has been under general anesthesia, she should be positioned on her side to facilitate drainage of secretions.* *2. It is important to observe the urine for a bloody tinge, which could mean surgical trauma to the bladder.* 3. Assessment of the level of anesthesia is performed for a client recovering from spinal anesthesia. *4. After a cesarean section, evaluate the dressing and perineal pad every 15 minutes for at least 1 hour.* *5. The fundus should be gently palpated to determine whether it is remaining firm.*

A client is suspected of having a hydatidiform mole. What should the nurse expect to assess in this client? Select all that apply. 1. Elevated blood pressure 2. Absence of fetal heart tones 3. Frequent urination and thirst 4. Dark brown vaginal drainage 5. Larger than gestational age fundal height

Answer: 1, 2, 4, 5 Explanation: 1. Manifestations of preeclampsia are associated with a hydatidiform mole, which would include an elevated blood pressure. 2. Fetal heart sounds are absent with a hydatidiform mole because a fetus is not developing in the uterus. 3. Frequent urination and thirst are not manifestations of hydatidiform mole. 4. Dark brown vaginal discharge, similar to prune juice, occurs because of liquefaction of the uterine clot. 5. Uterine enlargement greater than expected for gestational age is a classic sign of a complete mole, which is present in about half of cases. Enlargement is due to the proliferating trophoblastic tissue and to a large amount of clotted blood.

A pregnant client is in a motor vehicle crash and needs surgery to repair a fractured lower leg. What special precautions will this client need during and after the surgery? Select all that apply. 1. Prepare for intubation. 2. Insert a nasogastric tube. 3. Maintain on strict bed rest. 4. Insert an indwelling urinary catheter. 5. Apply sequential compression devices (SCDs).

Answer: 1, 2, 4, 5 Explanation: 1. Pregnancy causes increased secretions of the respiratory tract and engorgement of the nasal mucous membrane, often making breathing through the nose difficult. Consequently, pregnant women often need an endotracheal tube to maintain an airway during surgery. 2. The decreased intestinal motility and delayed gastric emptying that occur in pregnancy increase the risk of vomiting when anesthetics are given and during the postoperative period. A nasogastric tube may be recommended before major surgery. 3. Exercises in bed should be encouraged along with early ambulation after surgery. 4. An indwelling urinary catheter prevents bladder distention, decreases risk of injury to the bladder, and permits monitoring of output. 5. SCDs during and after surgery help prevent venous stasis and the development of thrombophlebitis.

The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply. 1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations

Answer: 1, 2, 5 Explanation: 1. The presence of prolonged decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 2. The presence of persistent late decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 3. Fetal activity is not used as an indication for intrauterine resuscitation. 4. A fetal heart rate of 140 bpm is within normal limits. 5. The presence of persistent and severe variable decelerations is a sign of monreassuring fetal status. Intrauterine resuscitation should be started without delay

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which participant statement indicates that additional information is needed? 1. "Because my hospital is so small and in a rural area, they will not let me attempt a VBAC." 2. "Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 3. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." 4. "My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down."

Answer: 2 Explanation: 1. A repeat cesarean must be able to be performed immediately to safely attempt a VBAC. Many small and rural hospitals do not have surgical and anesthesia staff available at night or on weekends and holidays, and therefore do not allow clients to have a VBAC. *2. Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classic vertical incisions on the uterus have a higher rate of rupture and should not be attempted.* 3. The incidence of uterine rupture is 0.5% to 0.9%. Women who have a successful VBAC have lower incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays. 4. Nonrepeating conditions such as any nonvertex presentation might make VBAC a viable option as long as this pregnancy is vertex.

The clinical nurse coordinator is reviewing the care of clients who undergo artificial rupture of membranes (AROM) by way of amniotomy with a group of nursing students. Which student statement indicates that the teaching has been effective? 1. "Amniotomy is contraindicated for use in labor augmentation." 2. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." 3. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'" 4. "In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed."

Answer: 2 Explanation: 1. Amniotomy is an accepted method of labor augmentation. *2. Following .AROM, because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal examinations must be kept to a minimum to reduce the chance of introducing an infection.* 3. Women need to know that amniotic fluid is constantly produced because some women may worry that they will experience a "dry birth." 4. In all cases, the .FHR is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared.

The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention? 1. Bladder is emptied using a straight catheter. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. Regional anesthesia is administered via pudendal block.

Answer: 2 Explanation: 1. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head. *2. The client should only push during contractions, not between contractions.* 3. These are normal fetal heart tones. No ntervention is needed. 4. Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.

The risk management nurse is reviewing labor and delivery statistics over the last 2 years in an effort to decrease costs of maternity care. What finding contributes to increased healthcare costs in clients undergoing cesarean birth by request? 1. Prolonged anemia, requiring blood transfusions every few months 2. Increased abnormal placenta implantation in subsequent pregnancies 3. Decreased use of general anesthesia with greater use of epidural anesthesia 4. Coordination of career projects of both partners leading to increased income

Answer: 2 Explanation: 1. This is not a complication of cesarean birth by request. *2. Placenta implantation problems are more common after cesarean birth and increase healthcare costs because of the high-risk care and testing required.* 3. Which anesthesia method is used is not a significant factor in healthcare costs of cesarean birth by request. The need for anesthesia, use of the operating suite, equipment use, personnel, and other factors are more responsible for greater costs of cesarean birth compared with vaginal birth. 4. The income of the couple does not affect healthcare costs directly.

A client experiencing a difficult labor has a vacuum extraction birth. What is expected with this type of delivery? 1. The head is delivered after eight pulls during contractions. 2. The location of the vacuum is apparent on the fetal scalp after birth. 3. A bruise is present on the occiput that does not cross the suture line. 4. Positive pressure is applied by the vacuum extraction during contractions.

Answer: 2 Explanation: 1. Use of the vacuum extraction for eight contractions is too many and can create damage to the fetal head. If fetal descent does not occur with the first two pulls, the procedure should be discontinued, and cesarean birth should take place. *2. Caput in the shape of the vacuum cup is usually present immediately after birth and resolves in 2 to 3 days.* 3. This is a cephalohematoma and is a complication of vacuum extraction birth. 4. Negative pressure is suction, which is needed to use the vacuum extractor to facilitate birth.

The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. What is the last assessment that the nurse should make before the client is draped for surgery? 1. Vaginal examination 2. Fetal heart tones 3. Maternal temperature 4. Maternal urine output

Answer: 2 Explanation: 1. Vaginal examination is unnecessary when CPD is present. *2. Fetal heart tones are assessed just prior to the start of surgery because the supine position can lead to fetal hypoxia.* 3. Maternal temperature is monitored by anesthesia personnel. 4. Maternal urine output is not significant at this point.

A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate? 1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4. Oxytocin administration

Answer: 2 Explanation: 1. Amniotomy is used to induce labor; however, a vaginal delivery is unlikely. 2. Cesarean section is the most likely course of action. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed. 3. Nipple stimulation is used to induce labor; however, a vaginal delivery is unlikely. 4. Oxytocin is used to induce labor; however, a vaginal delivery is unlikely

Which situation in the high-risk antepartal unit requires immediate intervention? 1. Fetal monitoring is being performed on a client in her third trimester who is scheduled for a cholecystectomy tomorrow. 2. A third-trimester client pregnant with twins who required an appendectomy yesterday is positioned in a supine position. 3. Oxygen is being administered at 2 L via nasal cannula to a client in her third trimester who underwent a urolithotomy today. 4. The client in her third trimester who returned from bowel resection surgery has a nasogastric tube attached to intermittent suction.

Answer: 2 Explanation: 1. Fetal monitoring prior to, during, and after surgery on pregnant clients is important to assess the fetal condition. 2. A client undergoing surgery in the third trimester should be positioned in a left lateral position or with a hip wedge placed under the right hip. Being supine will cause vena cava syndrome and hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger uterus and heavier uterine contents, makes vena cava syndrome more problematic. 3. Oxygen is required during and after surgery during pregnancy to maintain adequate fetal oxygenation. 4. Due to the decreased peristalsis of pregnancy, pregnant clients who undergo abdominal surgery are at risk for vomiting. A nasogastric tube is placed to prevent vomiting

The nurse is preparing teaching on maternal-fetal ABO incompatibility for antepartum clients. Which statement should the nurse include in the teaching information? 1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. 3. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction between the antigen sites on the maternal red blood cells (RBCs). 4. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type.

Answer: 2 Explanation: 1. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 3. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal red blood cells (RBCs). 4. Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type

The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important? 1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour.

Answer: 2 Explanation: 1. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions. 2. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow. 3. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority. 4. Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the client is hypotensive. Decreasing the IV rate will not improve fetal heart tones.

The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention? 1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4. Family refusing fetal autopsy

Answer: 2 Explanation: 1. Women with intrauterine fetal demise can demonstrate signs of an infection; however, this temperature is not high enough to indicate this problem. 2. Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level and indicates that the client is in DIC. 3. Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this is a normal platelet count. 4. Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is a higher priority.

The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply. 1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby.

Answer: 2, 3, 4 Explanation: 1. The fetus should not be removed from the room unless the client asks that the fetus be removed. 2. The fetus should be bathed/cleansed and wrapped in a blanket in preparation for viewing. 3. The client should be asked her preference for viewing and holding the baby. 4. It is inappropriate for the nurse to instruct the client on home care needed after delivery at this time. The client and family are having a highly emotional experience which should not be ignored. 5. Oftentimes other family members will be present and they should be asked of their desire to spend time with the baby.

A pregnant client receiving oxytocin for labor induction begins demonstrating adverse effects of the medication. In which order should the nurse provide care to this client? 1. Notify the healthcare provider. 2. Discontinue the oxytocin infusion. 3. Position the client onto the left side. 4. Infuse prescribed intravenous fluids. 5. Administer oxygen 8 to 10 L per tight face mask

Answer: 2, 4, 3, 5, 1 Explanation: 1. After applying oxygen the healthcare provider should be notified. 2. Nursing management of adverse effects begins by discontinuing the IV oxytocin infusion. 3. After intravenous fluids are started, the client should be turned onto the side. 4. After the oxytocin infusion is discontinued, the primary intravenous solution should be opened up for immediate infusion. 5. After positioning on the side, oxygen by tight face mask at 8 to 10 L/min should be administered.

A client in the midst of labor and delivery of twins is being considered for a podalic version. What should the nurse assess in order for this version to be considered? Select all that apply. 1. Previous cesarean birth 2. Second fetus does not descend 3. Premature rupture of membranes 4. Presence of third-trimester bleeding 5. Second fetus heart rate nonreassuring

Answer: 2, 5 Explanation: 1. A previous cesarean birth is a contraindication for a version. *2. A podalic version is used only with the second fetus during a vaginal twin birth and only if the twin does not descend readily.* 3. Premature rupture of membranes is a contraindication for a version. 4. Presence of third-trimester bleeding is a contraindication for a version. *5. A podalic version is used only with the second fetus during a vaginal twin birth and only if the heart rate is nonreassuring.*

The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement indicates that further information is required? 1. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 2. "Soaking in the tub will help my mediolateral episiotomy to heal." 3. "The tear I have through my rectum is unrelated to my episiotomy." 4. "Because I have a midline episiotomy, I should keep my perineum clean."

Answer: 3 Explanation: 1. Healing episiotomies can be very painful, and pain medication should be provided for clients experiencing pain. 2. Warm tub baths are helpful to facilitate both comfort and healing of an episiotomy. *3. This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum.* 4. When a client has an episiotomy, perineal hygiene is important to prevent infection and facilitate healing.

A client who received a mediolateral episiotomy to facilitate vacuum extraction birth asks what kind of episiotomy was performed. How should the nurse explain the location of the episiotomy? 1. "It goes straight back toward your rectum." 2. "It is from your vagina toward the urethra." 3. "It is cut diagonally away from your vagina." 4. "It extends from your vagina into your rectum."

Answer: 3 Explanation: 1. Midline episiotomy is straight back from the vagina toward the rectum. 2. Episiotomies are not cut anteriorly toward the urethra. *3. Mediolateral episiotomy is angled from the vaginal opening toward the buttock.* 4. Extension into the rectum is a fourth-degree laceration.

A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. How should the nurse respond to this request? 1. "I will get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I will bring you an extra so that you can change it when you are ready."

Answer: 3 Explanation: 1. Providing an additional ice pack before 20 minutes have passed would increase the perineal edema. 2. More than one ice pack must be used in order to apply ice for 20 minutes on, followed by 20 minutes off. *3. Optimal effects from the use of an ice pack occur when it is applied for 20 to 30 minutes and then removed for at least 20 minutes before being reapplied.* 4. An ice pack that is provided now for use in 20 minutes would be melted before being used.

A client experiencing a difficult labor is going to have vacuum extraction to facilitate delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "The baby's head might have a bruise from the vacuum cup." 2. "The vacuum will be applied for a total of 10 minutes or less." 3. "I can stop pushing and just rest if the vacuum extractor is used." 4. "A small cup will be put onto the baby's head, and a gentle suction will be applied."

Answer: 3 Explanation: 1. The vacuum extractor might leave a bruise on the scalp where the device is placed. 2. The vacuum extractor is applied to the scalp for up to 10 minutes total. *3. Vacuum extraction is an assistive delivery, and the client must continue with pushing efforts to accomplish the birth.* 4. The vacuum extractor is a small cup-shaped device that is applied to the scalp.

A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor? 1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4. Occiput anterior (OA) fetal position

Answer: 3 Explanation: 1. A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal bradycardia is a critical indicator of prolapsed cord. 2. Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is associated with maternal hemorrhage and failed placental separation after birth. 3. The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed. 4. The occiput anterior (OA) fetal position is amenable to delivery and would not represent a barrier to labor.

A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4. Monitor maternal blood pressure every 15 minutes.

Answer: 3 Explanation: 1. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 2. An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 3. This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture. 4. The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way.

The nurse receives the following report on a client who delivered 36 hours ago: para 1, rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse? 1. Administer rubella vaccine. 2. Ask if she is breast- or bottlefeeding. 3. Determine if RhoGAM has been given. 4. Discuss the discharge education with the client.

Answer: 3 Explanation: 1. The client is rubella immune and does not need the rubella vaccine. 2. This is important but is not the top priority. 3. The client is A-negative and the newborn B-positive. The client needs RhoGAM prior to discharge. Without RhoGAM, the client will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy. 4. Discharge education is always important, but in this case it is not the most important action

A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority? 1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV of lactated Ringer solution. 4. Apply antiembolism stockings.

Answer: 3 Explanation: 1. The client's partner or family member, or a nursery nurse, can feed the infant. The client is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time. 2. The placenta might be sent to pathology after it is removed, but preparing the client for manual removal of the placenta now is a higher priority. 3. The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary. 4. Antiembolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, antiembolism stockings are not needed for this client because manual removal of the placenta is not major surgery and does not lead to postprocedure immobility.

A client at 39 weeks' gestation being prepared for labor induction feels as though the baby has "flipped." What action should the nurse take? 1. Evaluate fetal maturity. 2. Administer dinoprostone (Cervidil) vaginal gel. 3. Implement continuous electronic fetal monitoring (EFM). 4. Notify the healthcare provider that the client feels as though the baby has changed position

Answer: 4 Explanation: 1. Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. 2. Dinoprostone (Cervidil) is used to facilitate cervical ripening, which might be premature since the fetal position needs to be evaluated before proceeding with the induction. 3. EFM will not provide enough information regarding the position of the fetus. *4. Because malpresentation, such as breech, is a relative contraindication to induction of labor, the client will require additional evaluation by the healthcare provider before proceeding.*

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. "Multipara, transverse lie." 2. "Primipara failed ECV last week." 3. "Primipara, frank breech ballotable." 4. "Multipara, 32 weeks, complete breech."

Answer: 4 Explanation: 1. This client has no contraindication to ECV. 2. Although this client is less likely to have a successful ECV this week if it were unsuccessful last week, there is no contraindication to attempting the procedure. 3. This client has no contraindication to ECV. *4. ECV is not attempted until 36 weeks. This client is too early in her pregnancy for ECV.*

A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. What action should the nurse make a priority at this time? 1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD).

Answer: 4 Explanation: 1. Oxygen will not hurt, but it is not the priority. 2. Terbutaline would not be recommended. The contraction pattern is incoordinate, but they need to be enhanced, not stopped. 3. An epidural will not change the incoordinate contraction pattern. 4. The client is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions.

The nurse instructs a client on the importance of reducing exposure to infections while pregnant. Which client statement indicates that teaching has been effective? 1. "My genital herpes infection will have no effect on my baby." 2. "Because I have toxoplasmosis, my baby might be born with an abnormally long body." 3. "The rubella infection I experienced in my second trimester may lead me to become deaf." 4. "My baby may develop a serious blood infection because I have group B strep in my vagina."

Answer: 4 Explanation: 1. Primary herpes simplex infection poses the greatest risk to both the mother and her infant. Primary infection has been associated with spontaneous abortion, low birth weight, and preterm birth. Transmission to the fetus almost always occurs after the membranes rupture and the virus ascends or during birth through an infected birth canal. 2. Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma, convulsions, or retinochoroiditis. 3. Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella. 4. Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are given during labor.

The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention? 1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."

Answer: 4 Explanation: 1. Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This client will be grieving but is not experiencing physical complications. 2. Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This client might be experiencing a complication, but it is a lower priority than the client with the possibility of a prolapsed cord. 3. Although this client is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency. 4. Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.

A postpartum client with blood type A, Rh-negative delivered a newborn with blood type AB, Rh-positive. Which statement indicates that teaching about this blood type inconsistency has been effective? 1. "Because my baby is Rh-positive, I do not need RhoGAM." 2. "Before my next pregnancy, I will need to have a RhoGAM shot." 3. "If my baby had the same blood type I do, it might cause complications." 4. "I need to get RhoGAM so I do not have problems with my next pregnancy."

Answer: 4 Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization. 2. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM). The injection must be given within 72 hours after delivery to prevent alloimmunization. 3. It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization. 4. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy.

A client with preeclampsia is assessed with the following: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. Which new assessment finding indicates the client's condition is getting worse? 1. Reflexes 2+ 2. Platelet count 150,000 3. Blood pressure 158/104 4. Urinary output 20 mL/hour

Answer: 4 Explanation: 1. The reflexes are normal at 2+. 2. The platelet count is normal, though it is at the lower end. 3. The blood pressure has not had a significant rise. 4. The decrease in urine output is an indication of decrease in glomerular filtration, which indicates a loss of renal perfusion. The assessment finding most abnormal and life threatening is the urine output change.

The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Clear fluid is leaking from the vagina." 3. "Client is positioned in a left lateral tilt." 4. "Entrance wound present below the umbilicus."

Answer: 4 Explanation: 1. These are normal vital signs, indicating a hemodynamically stable client. 2. Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term and would likely survive birth at this time. 3. Positioning the client in a lateral tilt position prevents vena cava syndrome. 4. Penetrating abdominal trauma has a 59% to 80% fetal injury rate. This fetus is at great risk for injury.

A 28-year-old woman at 16 weeks' gestation being screened for ABO incompatibility learns that her blood contains anti-A antibodies. What should the nurse explain about this finding? 1. "You may have contracted anti-A antibodies as a result of a viral infection." 2. "It's most likely that you contracted anti-A antibodies through sexual activity." 3. "Anti-A antibodies are inherited; usually, they are genetically passed down from father to daughter." 4. "Anti-A antibodies occur naturally, as a result of exposure to foods and different infections."

Answer: 4 Explanation: 1. Women develop anti-A and anti-B antibodies as a result of exposure to the A and B antigens through infection by gram-negative bacteria and not viruses. 2. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not contracted through sexual activity. 3. Women develop anti-A and anti-B antibodies naturally as a result of exposure to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not inherited. 4. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria.

The nurse is assisting a new mother to breastfeed. In which order should the nurse review the steps with the mother? 1. Bring the newborn to the breast. 2. The newborn opens mouth wide. 3. Tickle the newborn's lips with the nipple. 4. Have the newborn face the mother tummy-to- tummy. 5. Position the newborn so the newborn's nose is at level of the nipple.

5. Position the newborn so the newborn's nose is at level of the nipple 4. Have the newborn face the mother tummy-to- tummy. 1. Bring the newborn to the breast. 3. Tickle the newborn's lips with the nipple 2. The newborn opens mouth wide.

Which statement by a breastfeeding class participant indicates that teaching was effective? Select all that apply. 1. "Breastfeeding is worthwhile, even if it costs more overall." 2. "Breastfed infants get more skin-to- skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfeeding is complex and difficult, and I probably will not succeed."

2. "Breastfed infants get more skin-to- skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good."

A pregnant client has not decided on a feeding method for her infant and asks for more information about breastfeeding and formula-feeding. Which client statement indicates that the teaching was successful? 1. "Breastfeeding is more expensive than formula-feeding." 2. "My baby has a lower risk of food allergies if I breastfeed." 3. "Formula-feeding gives the baby protection from infections." 4. "Breast milk cannot be stored; it has to be thrown away after pumping."

2. "My baby has a lower risk of food allergies if I breastfeed."

Which information is least likely recorded as a part of the initial newborn assessment? 1. Presence or absence of meconium-stained fluid 2. Blood draw for phenylketonuria (PKU) screening 3. Resuscitative measures required in the birthing area 4. Parents' desires regarding circumcision for a male infant

2. Blood draw for phenylketonuria (PKU) screenin

The nurse is assisting a mother to bottle-feed her newborn, who has been crying. What should the nurse instruct the client to do before feeding the infant? 1. Offer a pacifier. 2. Burp the newborn. 3. Unwrap the newborn. 4. Stoke Stroke the newborn's spine and feet.

2. Burp the newborn

A client who delivered a day ago has chosen to breastfeed her infant. Which observation best indicates that the client understands breastfeeding? 1. The infant is crying when brought to the breast. 2. The client takes off her gown to achieve skin-to- skin contact. 3. The infant is held so that the nipple is accessed by turning the head. 4. The client puts the infant to breast when the baby is asleep to help wake the baby up.

2. The client takes off her gown to achieve skin-to- skin contact

During a postpartum home visit the nurse reinforces the importance of holding the infant and having tummy time periodically through the day with the new mother. What did the nurse observe that indicated the mother needed additional teaching? Select all that apply. 1. Rapid respiratory rate 2. Weak gross motor skills 3. Crusted nasal secretions 4. Positional plagiocephaly 5. Sluggish upper body strength

2. Weak gross motor skills 4. Positional plagiocephaly 5. Sluggish upper body strength

Answer: 71 kg

20) A client who weighed 60 kg before becoming pregnant with twins is having a routine prenatal examination at gestational week 24. What should be this client's weight in kilograms at this time? (Round to the nearest whole number.)

18) A client is identified as having hepatitis B surface antigen (HBsAG) early in her pregnancy. Which client statement about the labor and birth process and having hepatitis B infection indicates the need for additional teaching? 1. "Breastfeeding is a good feeding method for my baby." 2. "My baby will get a bath as soon as its temperature is stable." 3. "An internal fetal monitor will be applied as soon as possible during labor." 4. "Two shots will be given to my baby to prevent transmission of hepatitis B."

3. An internal fetal monitor will be avoided. Page Ref: 288

17) The prenatal clinic nurse has received four phone calls. Which client should be called back first? 1. Multipara at 11 weeks with untreated hyperthyroidism describing the onset of vaginal bleeding 2. Multipara at 6 weeks with a seizure disorder inquiring what foods are good sources of folic acid 3. Primipara at 28 weeks with a history of asthma reporting difficulty breathing and shortness of breath 4. Primipara at 35 weeks with a positive hepatitis B surface antigen (HBsAG) wondering what treatment her baby will receive after birth

3. Asthma exacerbations are most common between 24 and 36 weeks. Asthma attacks can lead to maternal hypoxia, which can lead to fetal hypoxia. This client is the top priority. Page Ref: 287

The mother of a newborn with iron deficiency anemia asks if breastfeeding or using a formula high in iron is better for the baby. How should the nurse respond? 1. Breastfeeding, because breast milk has higher levels of iron compared to formula 2. Formula-feeding, because formula has higher levels of iron compared to breast milk 3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 4. Formula-feeding, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant

3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant

The nurse is not familiar with the cultural background of new parents who have recently immigrated to the United States. What statement is best? 1. "You appear to be Muslim. Do you want your son to be circumcised?" 2. "Let me explain how newborn care takes place here in the United States." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain what your preferences are regarding child care?"

4. "Could you explain what your preferences are regarding child care?

An infant weighing 8 lb, 4 oz at birth weighs 7 lb, 15 oz 3 days later. What should the nurse explain to the parents about this change in the newborn's weight? 1. "This weight loss is unusual." 2. "This weight loss is less than expected." 3. "This weight loss is excessive." 4. "This weight loss is within normal limits."

4. "This weight loss is within normal limits."

A new adolescent mother is concerned about being able to properly care for the newborn at home because her mother thinks she is too young. What should the nurse say to this client? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."

4. "We can give the baby's bath together. I'll help you learn how to do it."

11) A client who is at 18 weeks' gestation has been newly diagnosed with megaloblastic anemia. Which client statement indicates teaching has been effective? 1. "My body makes red blood cells that are smaller than they should be." 2. "Megaloblastic anemia is not known to cause any serious risks to my baby." 3. "Whenever possible, I should boil my vegetables in at least 2 quarts of water." 4. "I should include fresh leafy green vegetables, red meat, fish, poultry, and legumes in my diet."

4. Folic acid, which is used to treat megaloblastic anemia, is readily available in foods such as fresh leafy green vegetables, red meat, fish, poultry, and legumes. Page Ref: 276

The nurse is assessing a 2-day- old male infant that has been circumcised. Which finding requires immediate intervention? 1. The umbilical cord clamp has been removed. 2. The mother is ready to breastfeed on demand. 3. The infant maintains temperature when wrapped in a blanket. 4. The infant has had a dry diaper since the circumcision procedure.

4. The infant has had a dry diaper since the circumcision procedure.

Answer: 2 Explanation: 1. Second- and third-trimester bleeding increases the risk for PPROM. 2. There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM. 3. A urinary tract infection (UTI) increases the risk for PPROM. 4. Multifetal gestation increases the risk for PPROM.

1) The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? 1. "If I have bleeding in the third trimester of my next pregnancy, I might rupture membranes again." 2. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 3. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 4. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured."

The nurse is teaching a class for new parents. Which statement indicates that additional information is needed? 1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it." 2. "Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother's circulation." 3. "We can call the nurse help line any time of day or night if we have questions about our baby after we get home." 4. "Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother."

1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it."

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "Giving the baby his first bath can really give me a chance to get to know him." 2. "Newborns cannot focus their eyes, so it does not matter how I hold my new baby." 3. "My baby will be very sleepy immediately after birth, so he can go to the nursery." 4. "I should avoid looking directly into the baby's eyes to prevent frightening the baby."

1. "Giving the baby his first bath can really give me a chance to get to know him."

The parents of a newborn are concerned that their baby continues to lose weight despite being held and cuddled. What should the nurse instruct tell these parents? Select all that apply. 1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 4. Gently flick the sole of the foot to stimulate. 5. Avoid stimulating when eye contact is absent.

1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 5. Avoid stimulating when eye contact is absent.

A change in skin color requires further assessment of which physiologic functions? Select all that apply. 1. Hematocrit 2. Oxygenation 3. Glucose levels 4. Blood pressure 5. Bilirubin levels

1. Hematocrit 2. Oxygenation 3. Glucose levels 5. Bilirubin levels

The elderly grandmother of a newborn tells the client that rubbing alcohol should be applied to the cord stump to make it dry and fall off faster. What should the nurse instruct the client about cord care? Select all that apply. 1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 3. Fold the diaper down under the cord stump. 4. Notify the healthcare provider if the cord stump appears dark in color. 5. Apply topical antibiotic ointment to the cord stump after each diaper change.

1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 3. Fold the diaper down under the cord stump

The nurse assesses a sleeping 1-hour- old, 39-weeks' gestation newborn. Which data should cause the nurse the most concern? 1. Respirations 68/min 2. Blood pressure 72/44 mmHg 3. Skin temperature 97.6°F 4. Heart rate 156 beats/min

1. Respirations 68/min

The nurse receives shift change reports on infants born within the last 4 hours. Which newborn should the nurse see first? 1. Term male, grunting respirations 2. 37-week male, respiratory rate 45 3. 8 lb, 1 oz female, pulse 150 4. 39-week female, temperature 97°F

1. Term male, grunting respirations

Which actions must a nurse perform before weighing the newborn during the admission procedure? Select all that apply. 1. Zero the scale. 2. Clean the scale. 3. Cover the scale. 4. Take the infant's temperature. 5. Wrap the infant tightly in a blanket to prevent heat loss.

1. Zero the scale. 2. Clean the scale. 3. Cover the scale

Answer: 3 Explanation: 1. The perinatal mortality rate for monoamniotic siblings is 10% to 32%. 2. Twins are more likely to have complications than are singleton births. 3. This is true. Spontaneously conceived twins are less likely to develop complications. 4. Primiparous women with twin pregnancies are more likely to develop complications.

11) A client pregnant with twins asks if the pregnancy will be uncomplicated. How should the nurse respond to this client? 1. "The perinatal mortality rate for monoamniotic siblings is 50%." 2. "Twins are less likely to have complications than are singleton births." 3. "Spontaneously conceived twins are less likely to develop complications." 4. "Primiparous women pregnant with twins are less likely to develop complications."

Answer: 21 g

16) A client with premature rupture of membranes received 4 g of magnesium sulfate at 1600 hours, followed by 2 g/hr beginning at 1700 hours. Birth occurred at 0130 hours. How many grams of magnesium sulfate did this client receive? Calculate to the nearest whole number.

Answer: 1 Explanation: 1. In a marginal placenta previa, the edge of the placenta is covered. 2. The internal os is completely covered in a complete placenta previa. 3. The internal os is partially covered in a partial placenta previa. 4. In a low-lying placenta previa, the placenta is implanted in the lower uterine segment but does not cover the os.

18) The nurse selects the following diagram to instruct a pregnant client with placenta previa. What should the nurse specifically teach the client about this health problem? 1. The edge of the placenta is covered. 2. The placenta completely covers the internal os. 3. The placenta is implanted with partial covering of the internal os. 4. The placenta is implanted in the lower uterine segment not covering the os.

Answer: 1, 2 Explanation: 1. Transabdominal cerclage placement typically results in a cesarean section birth. 2. Transabdominal cerclage placement requires a laparotomy for placement and removal. 3. Transabdominal cerclage placement does not increase the risk for hydramnios. 4. Transabdominal cerclage placement does not increase the risk for abruptio placentae. 5. Transabdominal cerclage placement does not increase the risk for premature rupture of membranes.

19) A pregnant client is scheduled for a transabdominal cerclage. What teaching information should the nurse prepare for this client? Select all that apply. 1. Cesarean section birth 2. Preoperative laparotomy 3. Potential for hydramnios 4. Risk for abruptio placentae 5. Premature rupture of membranes

Which safety device is most appropriate for the nurse who conducts home care visits to postpartum mothers? 1. Cellular phone 2. Map of the area 3. Personal handgun 4. Can of Mace

Answer: 1 Explanation: 1. Cellular phones provide a means of contact, and are advisable for the nurse to carry. 2. A map of the area should be checked before leaving for a visit, and the route traced. 3. Personal handguns are not permissible or legal for nurses to carry on home visits. 4. Mace is not permissible or legal for nurses to carry on home visits.

The newborn at 24 hours of age has a red blood cell (RBC) count of 5.4 million per milliliter. Which entry should the nurse expect to find in the newborn's chart to explain this laboratory value? 1. Cord clamping delayed until pulsation ceased. 2. Infant is breastfed 15 to 20 minutes every 3 hours. 3. CBC drawn from the anterior surface of the left hand. 4. Placental abruption noted to be 80% at time of delivery.

Answer: 1 Explanation: 1. Delayed cord clamping can cause an increase of up to 61%, resulting in a slightly higher-than-average RBC count. 2. Breastfeeding does not impact RBC counts in the first day of life. 3. Venous blood has lower RBC counts than do capillary blood samples. 4. Maternal or fetal blood loss causes hypovolemia and low RBC counts (less than 5.2 million per milliliter).

The nurse is teaching a postpartum client information regarding weaning her infant from breastfeeding. Which client statement suggests a need for further teaching? 1. "Slow weaning should take place over a period of several months." 2. "By weaning my baby slowly, I'm giving him time to change his eating method at his own pace." 3. "If I wean my baby slowly, I am less likely to develop breast engorgement." 4. "Slowly weaning my baby is recommended to allow time for my psychologic adjustment."

Answer: 1 Explanation: 1. During slow weaning, over a period of several weeks, the mother substitutes more cup feedings or bottlefeedings for breastfeedings. 2. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment. 3. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment. 4. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment.

The nurse is assessing the episiotomy of a client who is 2 days postpartum. In which order should the nurse complete this assessment? A. Edema B. Redness C. Ecchymosis D. Approximation E. Discharge/drainage 1. B, A, C, E, D 2. A, B, D, E, C 3. B, A, D, E, C 4. D, E, C, B, A

Answer: 1 Explanation: 1. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for redness, the nurse inspects the wound for edema.

The nurse manager of the neonatal intensive care unit is preparing a handout for new parents. Which statement should the nurse include? 1. Neonates have a tendency to become dehydrated. 2. Sugar is always present in the urine of a newborn. 3. The kidneys are fully functional by 30 weeks' gestation. 4. Newborns can eliminate excess fluid as quickly as an adult.

Answer: 1 Explanation: 1. Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus can become dehydrated easily. 2. Glucose is not identified as always being present in the urine of a newborn. 3. Full nephron function does not develop until 34 to 36 weeks. 4. Newborns have difficulty eliminating excess fluid because of their relatively low glomerular filtration rate during the first 2 weeks of life

The nurse is instructing a group of new parents about normal newborn behavior. Which attendee's statement indicates that teaching was effective? 1. "My baby will be able to hear very well immediately after birth." 2. "My baby will have difficulty seeing me close up right after delivery." 3. "My baby should be discouraged from sucking on a pacifier if being bottle fed." 4. "My baby should be trained to breastfeed by being encouraged to suck on a pacifier before feedings."

Answer: 1 Explanation: 1. Newborns have very acute hearing immediately after birth. 2. The newborn is nearsighted and has best vision at a distance of 8 to 15 inches. 3. For bottle-fed infants, there is no reason to discourage nonnutritive sucking with a pacifier. 4. Pacifiers should be offered to breastfed infants only after breastfeeding is well established or during prolonged times away from the mother, or when stressful or painful procedures are required.

The community nurse is caring for a client at 32 weeks' gestation diagnosed with preeclampsia. Which statement indicates that additional information is needed about the health problem? 1. "My urine may become darker and smaller in amount each day." 2. "Lying on my left side as much as possible is good for the baby." 3. "I should call the doctor if I develop a headache or blurred vision." 4. "Pain in the top of my abdomen is a sign my condition is worsening."

Answer: 1 Explanation: 1. Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. Oliguria should be reported to the healthcare provider. 2. Left lateral position maximizes uterine and renal blood flow and therefore is the optimal position for a client with preeclampsia. 3. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the healthcare provider. 4. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the healthcare provider.

The home care nurse notes jaundice on the skin over the sternum of a 3-day-old infant. What should the nurse explain to the parents about this finding? 1. "The liver of an infant is not fully mature and does not conjugate the bilirubin for excretion." 2. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 3. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." 4. "The infant received too many red blood cells after delivery because the cord was not clamped immediately."

Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence and peaks on day 3 or 4. 2. Frequent feeding will decrease jaundice. 3. Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels. 4. It happens in part because of the red blood cell destruction that infants experience combined with liver immaturity, which leads to less efficient conjugation of bilirubin for excretion

The nurse is instructing the parents of a newborn about the number of wet diapers to expect each day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "Feeding our baby frequently will help the kidneys function." 3. "Kidney function in an infant is very different from in an adult." 4. "A baby's kidneys do not concentrate urine well for several months."

Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue. 2. Frequent feeding helps maintain the fluid volume. 3. The ability to concentrate urine develops by 3 months of age. The inability to concentrate urine due to limited tubular reabsorption and lower glomerular filtration rate are the main differences between kidney function in a newborn and normal adult kidney function. 4. Counting wet diapers indicates urine output in relation to fluid intake.

The postpartum client, who delivered 4 hours ago, has a mediolateral episiotomy and large hemorrhoids. The client currently rates her pain at 7 on a scale of 1 to 10. She has a history of anaphylactic reaction to acetaminophen (Tylenol). Which nursing action is most appropriate? 1. Offering 800 mg ibuprofen (Advil) orally with food 2. Providing two oxycodone with acetaminophen tablets (Percocet) by mouth 3. Encouraging use of the prescribed topical anesthetic spray 4. Running very warm water into the tub and assisting her into the bath

Answer: 1 Explanation: 1. This is the best option because the client is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. 2. This medication is contraindicated because of the client's allergic reaction to acetaminophen. 3. Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a client has moderately severe pain. 4. Ice packs would be better at this stage because they will cause vasoconstriction to reduce edema and pain relief.

While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. What should the nurse immediately assess based upon this finding? 1. The clavicle 2. Babinski reflex 3. The rooting reflex 4. Ortolani maneuver

Answer: 1 Explanation: 1. When the Moro reflex is elicited, the newborn will straighten both arms and hands outward while the knees are flexed, then slowly return the arms to the chest, as in an embrace. If this response is not elicited, the nurse will assess the clavicle. If the clavicle is fractured, the response will be demonstrated on the unaffected side only. 2. The Babinski reflex tests for upper neuron abnormalities. 3. The rooting reflex is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck (if not fed recently). 4. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia.

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice in a 37-hour-old newborn. What information should the nurse gather first? 1. Skin color 2. Fluid intake 3. Bilirubin level 4. Stool characteristics

Answer: 1 Explanation: 1. Yellow coloration of the skin and sclerae is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice. 2. Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best determined by the number of wet diapers per day. 3. Skin color begins to appear yellow once the serum levels of bilirubin are about 4 to 6 mg/dL. 4. The stool characteristic of yellow-brown coloration indicates excretion of bilirubin

Page Ref: 510 Cognitive Level: Applying The nurse suspects that a newborn needs a complete neurologic examination by a healthcare provider. What finding did the nurse use to make this clinical decision? Select all that apply. 1. Absence of the plantar grasp 2. Absence of the truncal reflex 3. Presence of the stepping reflex 4. Presence of a nonnutritive sucking reflex 5. Presence of bringing the hand to the mouth

Answer: 1, 2 Rationale: 1. Absence of the plantar grasp requires neurologic evaluation. 2. Absence of the Galant (truncal) incurvation reflex requires neurologic evaluation. 3. The stepping reflex is an expected finding. 4. Nonnutritive sucking is an expected reflex. 5. Bringing the hand to the mouth is an expected action.

The nurse notes that a newborn has a dry scalp. What should the nurse include when teaching the parents about the care of this newborn? Select all that apply. 1. Use mild soap. 2. Use baby shampoo. 3. Wash the scalp daily. 4. Apply oil every other day. 5. Rinse the scalp with hot water.

Answer: 1, 2, 3 Explanation: 1. For scalp care the nurse should instruct the parents to shampoo the scalp with mild soap. 2. For scalp care the nurse should instruct the parents to shampoo the scalp with baby shampoo. 3. For scalp care the nurse should instruct the parents to shampoo the scalp and anterior fontanel areas daily. 4. For scalp care the nurse should instruct the parents to avoid the use of oil. 5. Hot water should not be used since this could burn the newborn's delicate tissues and skin.

The nurse is conducting discharge teaching for a postpartum client who has an episiotomy. Which client actions indicate correct understanding of the information presented? Select all that apply. 1. Using topical anesthetics regularly 2. Remaining in the sitz bath for 20 minutes 3. Using the peri-bottle to cleanse the site after urination 4. Stating that she will loosen her buttocks prior to sitting down 5. Stating that she will continue to use an ice pack for pain after discharge

Answer: 1, 2, 3 Explanation: 1. The use of topical anesthetics regularly after an episiotomy is a client action that indicates correct understanding of episiotomy care. 2. The postpartum client who remains in a sitz bath for 20 minutes is correctly caring for an episiotomy. 3. The use of a peri-bottle each time the postpartum client urinates indicates correct understanding of episiotomy care. 4. The postpartum client who states she will loosen her buttocks prior to sitting down will require additional education regarding episiotomy care. The client should tighten her buttocks prior to sitting down. 5. The postpartum client who states she will continue to use an ice pack for pain after discharge will require additional education regarding episiotomy care. Ice packs are only used for the first 24 hours.

A pregnant client diagnosed with Chlamydia trachomatis infection is refusing treatment. What effects on the fetus should the nurse explain might occur if treatment is waived? Select all that apply. 1. Fetal death 2. Premature labor 3. Newborn conjunctivitis 4. Chlamydial pneumonia 5. Ophthalmia neonatorum

Answer: 1, 2, 3, 4 Explanation: 1. Fetal death is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 2. Premature labor is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 3. An infant of a woman with untreated chlamydial infection may develop newborn conjunctivitis. 4. An infant of a woman with untreated chlamydial infection may develop chlamydial pneumonia. 5. Ophthalmia neonatorum is associated with gonorrhea.

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. 1. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." 2. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 3. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 4. "We should make sure that we keep our home air conditioned so the baby does not overheat." 5. "If the baby's body temperature gets too low, he will warm himself up without any shivering."

Answer: 1, 2, 3, 5 Explanation: 1. A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress. 2. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 3. Drying a wet baby prevents evaporation, one mechanism of heat loss. 4. Babies need to be kept warm. Cold ambient temperatures will increase the oxygen consumption of a newborn and can lead to respiratory distress. 5. Nonshivering thermogenesis is the mechanism used by newborns to warm themselves.

21) A client in labor is demonstrating acute manifestations of schizophrenia. What should the nurse identify as a priority for this client? Select all that apply. 1. Ensuring fetal well-being 2. Ensuring maternal well-being 3. Maintaining a safe environment 4. Medicating for pain as necessary 5. Considering pharmacologic intervention

Answer: 1, 2, 3, 5 Explanation: 1. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on ensuring fetal well-being. 2. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on ensuring maternal well-being. 3. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on maintaining a safe environment. 5. Pharmacologic interventions may be necessary for excessive symptoms. Page Ref: 280

Which will the nurse include in the family assessment for the postpartum client? Select all that apply. 1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 4. Signs and symptoms of infection 5. Level of comfort with newborn care

Answer: 1, 2, 3, 5 Explanation: 1. The nurse assesses parental role adjustment during the family assessment for the postpartum client. 2. The nurse assesses bonding behaviors during the family assessment for the postpartum client. 3. The nurse assesses sibling adjustment during the family assessment for the postpartum client. 4. Clinical manifestations of infection are assessed during the physical assessment, not the family assessment, for the postpartum client. 5. The nurse assesses level of comfort with newborn care during the family assessment for the postpartum client.

A client delivered a fetus with the following head shape: On what should the nurse focus when assessing this newborn? Select all that apply. 1. Airway 2. Amount of bruising 3. Meconium aspiration 4. Degree of facial edema 5. Neck and head movement

Answer: 1, 2, 4, 5 Explanation: 1. Because of neck compression the trachea and larynx may be compressed, compromising this newborn's airway. 2. Because of the presentation, bruising may occur to the face. 3. Meconium aspiration is not associated with this type of delivery. 4. Because of the presentation, facial edema may occur. 5. Because of cerebral and neck compression, neck and head range of motion may be compromised.

Which is the obese postpartum client at a greater risk for experiencing? Select all that apply. 1. Injury 2. Infection 3. Breast engorgement 4. Deep vein thrombosis 5. Respiratory complications

Answer: 1, 2, 4, 5 Explanation: 1. The obese postpartum client is at a greater risk for injury. 2. The obese postpartum client is at a greater risk for infection. 3. The obese postpartum client is not at a greater risk for breast engorgement. 4. The obese postpartum client is at a greater risk for thromboembolic disease, such as deep vein thrombosis (DVT). 5. The obese postpartum client is at a greater risk for respiratory complications.

The nurse is providing care to a lesbian postpartum client and her life partner. Which nursing actions are appropriate when providing care to this couple? Select all that apply. 1. Providing the couple with the same rights and care as those given to heterosexual couples 2. Educating the couple about heterosexual contraception during the postpartum period 3. Teaching the couple about when it is safe to resume sexual relations 4. Encouraging the couple to join a support group of other postpartum lesbian couples 5. Expecting the nonpregnant partner to assume the role of father

Answer: 1, 3, 4 Explanation: 1. Lesbian couples should be given the same rights and care as heterosexual couples in the acute care environment. 2. Contraception teaching during the postpartum period will differ for the lesbian client versus the heterosexual client as there is no need to educate about heterosexual contraception. 3. Lesbian couples require education regarding the safe resumption of sexual relations. 4. Lesbian couples should be encouraged to seek support, including joining a support group with other postpartum lesbian couples. 5. Evidence shows that the nonpregnant partner will assume the comothering role, not the role of the father.

A newborn is demonstrating signs of needing comfort and security. What should the nurse instruct the parents about swaddling this infant? Select all that apply. 1. Swaddling should be loose. 2. Swaddling should be done with the arms at the sides. 3. Swaddling helps the newborn control body movements. 4. Swaddling should permit the newborn access to the mouth. 5. Swaddling should be tightly bound around the infant's torso.

Answer: 1, 3, 4 Explanation: 1. Swaddling newborns is a way to provide comfort and security. Blanket swaddling should be loose. 2. Swaddling newborns is a way to provide comfort and security. Tight swaddling with arms at sides is not comforting and may further agitate the infant. 3. Swaddling newborns is a way to provide comfort and security. Swaddling helps the newborn control body movements. 4. Swaddling newborns is a way to provide comfort and security. Blanket swaddling allows the infant easy hand to mouth access to promote self-soothing abilities. 5. Swaddling newborns is a way to provide comfort and security. Tight swaddling is not comforting and may further agitate the infant.

The nurse is caring for a postpartum client who is 4 hours postoperative following a cesarean birth. Which nursing interventions are appropriate based on these data? Select all that apply. 1. Administering the prescribed analgesics, as needed 2. Encouraging ambulation to the bathroom to void 3. Encouraging leg exercises every 2 hours 4. Encouraging coughing and deep breathing every 2 to 4 hours 5. Encouraging the use of breathing, relaxation, and distraction

Answer: 1, 3, 4, 5 Explanation: 1. Administering the prescribed analgesics, as needed, addresses the client's nursing care needs, which are similar to those of other surgical clients. 2. Encouraging the client to ambulate to the bathroom to void is not an appropriate intervention for a postpartum client who is 4 hours postoperative for a cesarean birth. 3. Encouraging leg exercises addresses the client's nursing care needs, which are similar to those of other surgical clients. 4. Encouraging coughing and deep breathing every 2 to 4 hours addresses the client's nursing care needs, which are similar to those of other surgical clients. 5. Encouraging the use of breathing, relaxation, and distraction addresses the client's nursing care needs, which are similar to those of other surgical clients.

The nurse is planning to assess a newborn's neurologic status. Which behaviors should the nurse focus on during this assessment? Select all that apply. 1. Cry 2. Reflexes 3. Alertness 4. Motor activity 5. Resting posture

Answer: 1, 3, 4, 5 Explanation: 1. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include cry. 2. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Reflexes are elicited; not observed. 3. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include the state of alertness. 4. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include motor activity. 5. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include resting posture.

The nurse notes that a newborn has tremor-like movements. For which health problems should this newborn be further assessed? Select all that apply. 1. Seizures 2. Bilirubinemia 3. Hypocalcemia 4. Hypoglycemia 5. Substance withdrawal

Answer: 1, 3, 4, 5 Explanation: 1. Tremors or tremor-like movements must be evaluated to differentiate the tremors from seizures. 2. Bilirubinemia is not identified as causing tremors in a newborn. 3. Tremors may be related to hypocalcemia. 4. Tremors may be related to hypoglycemia. 5. Tremors may be related to substance withdrawal.

What amount of weight loss, in pounds, should the nurse expect in an average postpartum client? 1. 5 to 8 2. 10 to 12 3. 12 to 15 4. 15 to 20

Answer: 2 Explanation: 1. A loss of 5 to 8 lb might occur after a preterm birth. 2. A loss of 10 to 12 lb is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid. 3. A loss of 12 to 15 lb does not match the usual weight of placenta, amniotic fluid, and full-term infant weight. 4. A loss of 15 to 20 lb might occur after a multiple birth.

The nurse is making a visit to the home of a new mother. Which observation indicates that the mother and infant are in the phase of mutual regulation? 1. The infant grasps the mother's finger while nursing. 2. The mother vocalizes feelings of frustration with her infant. 3. The infant begins to seek out the mother over other individuals. 4. The mother spends more time making eye-to-eye contact with the infant.

Answer: 2 Explanation: 1. Actions that make the infant more attractive to the mother, such as grasping a finger, usually occur during the acquaintance phase. 2. The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship. 3. When the relationship between mother and infant reaches reciprocity, the infant will seek to interact with the mother more. 4. Holding the infant in the en face position is likely to occur most often in the acquaintance phase.

The new father asks what his baby will experience while sleeping and awake. How should the nurse respond? 1. "Babies have several sleep and alert states. Keep watching and you will notice them." 2. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 3. "You may have noticed that your child was in an alert awake state for an hour after his birth." 4. "Birth is hard work for babies; it takes them a week or 2 to recover and become more awake."

Answer: 2 Explanation: 1. Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. This is not the best response. 2. This statement is true. Teaching the parents how to detect the two sleep stages helps them tune in to their infant's behavioral states. 3. Although this statement is true, it does not respond to the father's question about sleeping now. 4. Recovery from the birth process only takes a day or 2. During that time, feedings should take place when the baby is in an alert state.

The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago. Assessment findings include: the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB ↓ the uterus; client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which nursing diagnosis has the highest priority for this client? 1. Acute Pain related to perineal trauma 2. Risk for Deficient Fluid Volume related to uterine bleeding and nausea 3. Readiness for Enhanced Family Coping related to vaginal childbirth experience 4. Knowledge Deficit related to newborn care

Answer: 2 Explanation: 1. Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit. 2. Adequate fluid volume is a critical physiologic need; therefore, this is the highest-priority nursing diagnosis. 3. Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit. 4. Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the physiologic need for adequate fluid volume.

Every time the nurse enters the client's room, the client, who delivered 3 hours ago, asks the nurse something else about the birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert attention to other subjects. 2. Review documentation of the birth experience and discuss it with the client. 3. Contact the healthcare provider because of changes in the client's memory. 4. Submit a referral to Social Services because of concerns about obsessive behavior.

Answer: 2 Explanation: 1. Answering questions quickly and trying to divert attention to other subjects trivializes the questions and does not allow the client to sort out the reality from the subjective experience. 2. Reviewing the documentation of the birth experience and discussing it with the client helps the client integrate the experience and talk about perceptions of the labor and delivery experience. 3. The client is not demonstrating changes in memory. The healthcare provider does not need to be contacted. 4. Submitting a referral to Social Services because of obsessive behavior is not appropriate. The client is demonstrating normal behavior.

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Antibiotics decrease the incidence of hyperbilirubinemia. 2. Total bilirubin is the sum of the direct and indirect levels. 3. Conjugated bilirubin is eliminated in the conjugated state. 4. Unconjugated bilirubin is neurotoxic and cannot cross the placenta.

Answer: 2 Explanation: 1. Because of the role of gut bacteria in converting conjugated bilirubin into urobilinogen, neonates who have been administered antibiotics have an increased incidence of hyperbilirubinemia. 2. This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is also referred to as indirect. 3. Conjugated bilirubin can be transformed back into unconjugated bilirubin prior to excretion by β-glucuronidase enzyme if gut bacteria have not transformed it into urobilinogen. 4. Unconjugated bilirubin is neurotoxic but crosses the placenta during fetal life for the maternal gastrointestinal system to conjugate and excrete.

On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. What should the nurse identify as the reason for the client's memory lapse? 1. Epidural anesthesia 2. The taking-in phase 3. The taking-hold phase 4. Postpartum hemorrhage

Answer: 2 Explanation: 1. Epidural anesthesia is a pharmacologic approach to pain control. 2. The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest. 3. The taking-hold phase occurs by the second or third day, when the mother is ready to resume control of life and is open to teaching. 4. Postpartum hemorrhage is a serious complication and will need medical intervention.

The nurse palpates the following when conducting a vaginal assessment on a client in labor: What action should the nurse take to address this finding? 1. Position the client on the left side. 2. Prepare the client for cesarean section. 3. Place a wedge under the client's right hip. 4. Increase intravenous fluids and apply oxygen.

Answer: 2 Explanation: 1. Positioning on the left side will not change the fetal position. 2. The fetus is in the transverse lie. The client needs to be prepared for a cesarean birth. 3. Placing a wedge under the right hip will not change the fetal position. 4. The client is not in any acute distress. Intravenous fluid bolus and oxygen are not required

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a bright green stool. How should the nurse respond to the client? 1. "Your newborn has diarrhea." 2. "This is a normal occurrence." 3. "There may be a possible food allergy." 4. "Take your newborn to the pediatrician."

Answer: 2 Explanation: 1. The green color of stool is not characterized as diarrhea, but is a transitional stool that consists of part meconium and part fecal material. 2. By the third day of life, the newborn's stools appear brown to green in color. 3. The green color of stool is not due to food allergies. 4. It is not necessary for the client to take her newborn to the pediatrician

A postpartum client is not going to breastfeed her newborn. What should the nurse include when teaching this client about breast care? 1. The let-down reflex 2. Lactation suppression 3. The purpose of fundal massage 4. The cause of afterpains

Answer: 2 Explanation: 1. The let-down reflex is an important teaching point for breastfeeding patients. 2. It is important to teach nonbreastfeeding patients about lactation suppression after delivery. 3. The purpose of fundal massage should be addressed when assessing the uterus and fundus, not when assessing the breasts. 4. Afterpains can be stimulated by breastfeeding. The nurse will not likely teach a nonbreastfeeding primipara about afterpains.

A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. What is the appropriate nursing intervention for this patient? 1. Contact Social Services with concerns of neglect. 2. Teach the client how to interact appropriately with the infant. 3. Take the infant to the nursery so the baby can receive more consistent care. 4. Provide the care the infant needs while continuing to evaluate the mother's actions.

Answer: 2 Explanation: 1. The mother may only need some education on how to care for her infant. If the nurse consistently teaches the mother and encourages mother-infant interaction and the mother continues to ignore the child, then it may be appropriate to contact Social Services in extreme circumstances. 2. New mothers may be hesitant to care for the infant because of feelings of inadequacy. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention. 3. Instead of encouraging mother-infant bonding, this action may emotionally distance the mother from her child even more. It may also confirm the mother's feelings of inadequacy. 4. While this action does provide for the needs of the newborn during the hospital stay, it does not help the mother know how to care for her child once she returns home.

The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth? 1. Scarf sign 2. Arm recoil 3. Popliteal angle 4. Square window sign

Answer: 2 Explanation: 1. The scarf sign is elicited by placing the newborn supine and drawing an arm across the chest toward the newborn's opposite shoulder until resistance is met. A preterm infant's elbow will cross the midline of the chest, whereas a full-term infant's elbow will not cross midline. 2. Recoil time is slower in fatigued newborns. Therefore, arm recoil is best elicited after the first hour of birth so the newborn can recover from the stress of birth. 3. The popliteal angle (degree of knee flexion) is determined with the newborn flat on the back. The thigh is flexed on the abdomen and chest, and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is then measured. Results vary from no resistance in the very immature newborn to an 80-degree angle in the term newborn. 4. The square window sign is elicited by gently flexing the newborn's hand toward the ventral forearm until resistance is felt. The angle formed at the wrist is measured.

The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first? 1. Multipara, second day postcesarean, moderate lochia serosa 2. Primipara, day of delivery, fundus firm 2 cm above umbilicus 3. Multipara, first postpartum day, 4 cm diastasis recti abdominis 4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants

Answer: 2 Explanation: 1. This client is not experiencing any unexpected findings. 2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding. 3. This finding is normal, especially in a multiparous client. 4. Bowel sounds are often decreased after delivery.

The mother of a 2-day-old infant newly diagnosed with sepsis asks why she could not detect the symptoms. What should the nurse reply to this mother? 1. "Your mothering skills will improve with time. You should take the newborn class." 2. "Newborns have immature immune function at birth, and illness is very hard to detect." 3. "Your baby did not get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero does not start to function until 4 to 8 weeks of age."

Answer: 2 Explanation: 1. This response does not address the physiology of neonatal infection and is not therapeutic because it is blaming. 2. The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn. 3. The mother develops active acquired immunity, which is passed to the newborn transplacentally as passive acquired immunity. This immunity is to the illnesses and infections she has had or been immunized against. 4. The passive acquired immunity a newborn receives from its mother is effective at birth and lasts from 4 weeks to 8 months, depending on the specific antibody.

The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." Which response by the nurse is most appropriate? 1. "We'll take good care of you and your baby. You'll be home before you know it." 2. "You'll be wearing sequential compression devices to prevent blood clots from forming in your legs." 3. "You will have a lot of pain, but there are medications that we give when it gets bad." 4. "You won't be able to nurse until the baby is 12 hours old because of your epidural."

Answer: 2 Explanation: 1. This response focuses on the nurse, and does not provide specific information to answer the client's question. 2. Sequential compression devices (SCDs) are used until the client is up and walking to prevent thrombus formation. 3. Focusing on the pain is a negative emphasis. In addition, pain medications work best when they are taken as the pain is intensifying; medication should not be delayed until the pain is severe, as less relief will be obtained. 4. Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother's ability to breastfeed. She might need some assistance with positioning the infant due to bed rest, but should be encouraged to breastfeed as soon as possible.

The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene? 1. Asking the client to void before applying clean gloves 2. Instructing visitors to leave the room prior to beginning the assessment 3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment 4. Discussing the effectiveness of comfort measures while performing the perineal assessment

Answer: 2 Explanation: 1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids. 2. The nurse should allow the client to choose whether visitors leave or remain in the room during the assessment. 3. The supine position prevents a falsely high assessment of fundal height. 4. The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures.

The nurse is caring for a client who delivered by cesarean birth and during which she received a general anesthetic. Which will the nurse encourage to prevent or minimize abdominal distention? Select all that apply. 1. Increasing intake of cold beverages 2. Participating in leg exercises every 2 hours 3. Tightening the abdominal muscles 4. Ambulating as often as possible 5. Eating a high-protein general diet

Answer: 2, 3, 4 Explanation: 1. Increased intake of cold beverages would increase the distention through increase of gas and constipation. 2. Participating in leg exercises every 2 hours serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 3. Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 4. Ambulating as often as possible serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 5. Eating a high-protein general diet would increase the distention through increase of gas and constipation.

The nurse is caring for a client who plans to relinquish her baby for adoption. Which nursing actions are appropriate based on this information? Select all that apply. 1. Encourage the client to see and hold her infant. 2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow for access to the infant if the client requests it.

Answer: 2, 3, 4, 5 Explanation: 1. Encouraging the client to see and hold her infant does not respect the client's right to refuse interaction, and might make her feel guilty for not wanting to see the infant. 2. Encouraging the client to express emotions is an aspect of providing care for the client who decides to relinquish her infant. 3. Respecting any special request for the birth is an aspect of providing care for the client who decides to relinquish her infant. 4. Acknowledging the grieving process is an aspect of providing care for the client who decides to relinquish her infant. 5. Allowing for access to the infant at the client's request is an aspect of providing care for the client who decides to relinquish her infant.

The nurse decides that a family with a newborn would benefit from a Social Services consultation. What statements were made by family members that caused the nurse to make this decision? Select all that apply. 1. "I think we're getting along better." 2. "I'm not going to let a baby make me fat." 3. "My mother could care less about this baby." 4. "At least help me if you don't want to get a job." 5. "That's fine. Go to work. Leave me here to do all of the work."

Answer: 2, 3, 4, 5 Explanation: 1. The statement about getting along would indicate adapting to the new infant. 2. Preoccupation with physical status or weight could indicate adjustment difficulties. 3. Lack of support systems could indicate adjustment difficulties. 4. Unemployment could indicate adjustment difficulties. 5. Marital problems could indicate adjustment difficulties.

The nurse is instructing a postpartum client on the use of perineal pads. Which statements should the nurse include in the teaching session? Select all that apply. 1. "Apply the pad from back to front." 2. "Change the pad after each perineal cleansing." 3. "Place the pad so that it applies pressure to the perineum." 4. "Change the pad each time you use the bathroom." 5. "Your pad should be loose to allow the perineum to 'breathe.' "

Answer: 2, 4 Explanation: 1. The perineal pad should be applied from front to back, not back to front, to decrease the risk of contamination. 2. The perineal pad should be changed after each perineal cleansing. 3. The perineal pad should be placed snugly against the perineum but should not produce pressure. 4. The perineal pad should be changed after urination and defecation. 5. The perineal pad should be placed snugly against the perineum. If the pad is worn too loosely, it may rub back and forth, irritating perineal tissues and causing contamination between anal and vaginal areas.

During a home visit the nurse is concerned that a new mother is experiencing postpartum blues. What did the nurse assess to make this clinical determination? Select all that apply. 1. Fear 2. Anger 3. Euphoria 4. Anorexia 5. Weepiness

Answer: 2, 4, 5 Explanation: 1. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Fear is not commonly associated with postpartum blues. 2. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anger. 3. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Euphoria is not commonly associated with postpartum blues. 4. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anorexia. 5. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by weepiness.

23) A 32-year-old pregnant client is diagnosed with active tuberculosis (TB). What fetal health issues is this client at risk for developing? Select all that apply. 1. Cleft palate 2. Preterm labor 3. Microcephaly 4. Spontaneous abortion 5. Suboptimal weight gain

Answer: 2, 4, 5 Explanation: 2. Women with TB have a higher rate of preterm labor. 4. Women with TB have a higher rate of spontaneous abortion. 5. Women with TB have a higher rate of suboptimal weight gain. Page Ref: 289

The nurse is caring for an adolescent client who gave birth to her first child yesterday. Which nursing action indicates accurate understanding of adolescent parenting concepts? 1. The client's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby during the assessment. 4. A discussion on contraceptive methods is the first topic of teaching.

Answer: 3 Explanation: 1. Although the parents of adolescents are often involved with child care and childrearing, this action is only appropriate if the client desires to have her mother present for teaching and discussions. 2. Involvement of the father is important, but having the mother learn more about her new baby and what the behavior cues are is a higher priority. 3. This helps the client learn about her baby and understand the baby as an individual, and facilitates maternal-infant attachment. This is the highest priority. 4. Adolescents are statistically more likely to have another child during their adolescence, but establishing a rapport and facilitating understanding of and attachment to the newborn is a higher priority.

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I cannot believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract moves things along at birth." 3. "Incredibly, his stomach capacity is already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days."

Answer: 3 Explanation: 1. At birth, neonates can digest fats, simple carbohydrates, and proteins. 2. Gastric emptying and intestinal peristalsis occur during in utero life; the first bowel movement usually occurs in the first day of life. 3. A newborn's stomach capacity is only 50 to 60 mL; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying. 4. Neonates lose 5% to 10 % of their birth weight in the first days after life, especially if they are breastfed. They should have regained the lost weight and should be back to their birth weight by 10 days of age.

The nurse attempts to take the vital sign of the newborn, but the newborn is crying. What intervention would be appropriate? 1. Taking the vital signs 2. Waiting until the newborn stops crying 3. Placing a gloved finger in the newborn's mouth 4. Swaddling the newborn with several warm blankets in an attempt to calm the newborn

Answer: 3 Explanation: 1. Crying will increase heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. 2. Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might be too long of a delay. 3. To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth. 4. Swaddling an infant with warm blankets can cause the infant to become overheated and increase restlessness.

The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice? 1. Molding 2. Mongolian spots 3. Cephalohematoma 4. Telangiectatic nevi

Answer: 3 Explanation: 1. Molding is caused by overriding of the cranial bones. 2. Mongolian spots are macular areas of bluish black pigmentation on the dorsal area of the buttocks. 3. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. The red blood cells present in the cephalohematoma begin to break down, which can lead to an increase in bilirubin levels in the blood. 4. Telangiectatic nevi are pale pink or red spots found on the eyelids, nose, lower occipital bone, or nape of the neck.

On the second day postpartum, the client who is bottlefeeding experiences engorgement. Which should the nurse encourage to enhance the client's comfort? 1. Removing her bra 2. Applying heat to her breasts 3. Applying ice packs to her breasts 4. Limiting breastfeeding to twice daily

Answer: 3 Explanation: 1. Removing her bra will only serve to increase breast milk production. A tight-fitting bra should be worn at all times for 5 to 7 days and only removed when showering. 2. Applying heat will promote breast milk production. 3. Applying ice packs to the breasts relieves discomfort through the numbing effect of ice. 4. Limiting breastfeeding to twice per day actually would decrease the flow of breast milk eventually, and would not serve to decrease the discomfort of the mother.

The maternal home care nurse, who is orienting a new nurse, discusses maternal psychologic adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal clients? 1. "Because emotional disorders and imbalances are a very sensitive subject, we try not to offend clients by routinely bringing up the topic of postpartum depression." 2. "For women with a history of depression, we include education about postpartum depression." 3. "Teaching about postpartum depression is a routine part of education for all maternal clients." 4. "If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic."

Answer: 3 Explanation: 1. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 2. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 3. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 4. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? 1. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychologic approach to family bonding. 2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on the stomach." 3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." 4. "Cosleeping is not recommended; however, if you wish to do this, place your baby on a comforter, as opposed to directly on the mattress."

Answer: 3 Explanation: 1. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for sudden infant death syndrome (SIDS). 2. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Families who practice cosleeping require appropriate teaching measures, which include making sure the baby is sleeping on the back, not on the stomach. 3. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety guidelines 4. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Safety guidelines related to cosleeping include placing the infant on a firm mattress, never on comforters, pillows, or a waterbed.

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. How should the nurse interpret this finding? 1. Prematurity 2. Facial paralysis 3. A normal position 4. A possible chromosomal abnormality

Answer: 3 Explanation: 1. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 2. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 3. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 4. Low-set ears could indicate a chromosomal abnormality.

The nurse is performing an assessment of early attachment. Which action indicates that the client is pleased with the baby's appearance and sex? 1. The mother enfolds the infant in her arms. 2. The mother feeds the infant every 2 to 3 hours as instructed. 3. The mother points out family traits she sees in the newborn. 4. The mother asks questions about how to properly bathe her infant.

Answer: 3 Explanation: 1. This action can be used to assess if the mother is attracted to her newborn and is forming emotional attachments with the newborn. 2. This action can be used to assess the ability of the mother to care for the infant's needs as they arise. 3. This action will help determine if the mother is pleased with her baby's appearance. She may point out both positive and negative traits. 4. This action helps assess the mother's willingness to learn how to care for her infant.

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Mean blood pressure 55 mmHg 2. Pulse rate 145, systolic murmur heard 3. Pauses in respiration lasting 30 seconds 4. Respiratory rate 60, crackles present bilaterally

Answer: 3 Explanation: 1. This is a normal finding in an infant at 1 hour of life. 2. This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale. 3. Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention. 4. This respiratory rate is normal; crackles are commonly heard in the first few hours after birth as the infant reabsorbs the fluid in the lungs that was present at birth.

A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. What should the nurse explain about this occurrence? 1. "Do not worry. I will make sure everything is fine." 2. "We see this from time to time. It's not a big deal." 3. "Blood has pooled in the vagina while you were in bed." 4. "The gush is an indication that your fundus is not contracting."

Answer: 3 Explanation: 1. This response is not therapeutic because it focuses on the nurse and has a "do not worry" aspect that is demeaning. 2. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not address the client's concern. 3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semisitting in bed, which leads to a gush when fundal massage is performed. 4. The fundus might be contracting well. The gush is from pooled lochia in the vagina/

A pregnant client at 14 weeks' gestation is diagnosed with hyperemesis gravidarum. The most recent vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Encourage clear liquids orally. 3. Give 1 L of lactated Ringer solution IV. 4. Administer 30 mL Maalox (magnesium hydroxide) orally.

Answer: 3 Explanation: 1. Weighing the client provides information on weight gain or loss, but it is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The client needs IV fluids. 2. The client needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a client with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia. 3. The vital signs indicate hypovolemia. Giving this client a liter of lactated Ringer solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down. 4. The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. The client needs IV fluids.

The nurse notes the presence of a cephalohematoma on the head of a newborn. What did the nurse use to make this clinical determination? Select all that apply. 1. The head appears asymmetric. 2. The mass overrides the suture line. 3. The mass appears only on one side of the head. 4. The mass appeared on the second day after birth. 5. The mass appears larger when the newborn cries.

Answer: 3, 4 Explanation: 1. Molding causes the head to appear asymmetric; this is due to the overriding of cranial bones during labor and birth. 2. Cephalohematomas do not cross the suture lines. 3. Cephalohematomas can be unilateral or bilateral. 4. A cephalohematoma can appear between the first and second day after birth. 5. A cephalohematoma does not increase in size when the newborn cries.

A new mother is concerned because the anterior fontanelle swells when the newborn cries. What normal findings should the nurse include when teaching the new mother about this concern? Select all that apply. 1. The fontanelles might bulge. 2. The fontanelles might be depressed. 3. The fontanelles can swell with crying. 4. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed.

Answer: 3, 4, 5 Explanation: 1. Bulging fontanelles signify increased intracranial pressure. 2. Depressed fontanelles indicate dehydration. 3. Newborn fontanelles can swell when the newborn cries. 4. Newborn fontanelles can pulsate with the heartbeat. 5. Newborn fontanelles can swell when the newborn passes a stool.

In which order should the nurse conduct the examination of a postpartum client? 1. L-lochia 2. B-bowel 3. B-breast 4. U-uterus 5. B-bladder 6. E-emotional 7. H-Homans/hemorrhoids 8. E-episiotomy/laceration/edema

Answer: 3, 4, 5, 2, 1, 8, 7, 6 Explanation: An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B-breast, U-uterus, B-bladder, B-bowel, L-lochia, E-episiotomy/laceration/edema, H-Homans/hemorrhoids, E-emotional.

For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. What should the nurse include when explaining the location of the episiotomy to the client? 1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4. "Through your rectal sphincter."

Answer: 4 Explanation: 1. A periurethral laceration is near the urethra. 2. A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle. 3. A fourth-degree laceration is through the rectal mucosa. 4. A third-degree laceration includes the rectal sphincter

The nurse is preparing material to instruct a client who has given birth to her first child. What aspect of teaching is most important? 1. Determine if father-infant attachment is taking place. 2. Discuss adaptation to grandparenthood by her parents. 3. Describe the likely reaction of siblings to the new baby. 4. Assist the mother in identifying behavior cues of the baby.

Answer: 4 Explanation: 1. Although father-infant attachment is important, the mother is the main client, and teaching her directly is a higher priority. 2. Adaptation to grandparenthood is a task for her parents and not a high priority for teaching the new mother. 3. This is not appropriate because the baby has no siblings. 4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment.

Nursing students describe actions while practicing physical assessment of a newborn using a model. Which nursing student's statement indicates the need for further teaching? 1. "I auscultated the infant's heart tones for 1 minute." 2. "I palpated peripheral pulses in all the newborn's extremities." 3. "I obtained a higher blood pressure on the legs than on the arms." 4. "I obtained the infant's heart rate by observing the cardiac monitor."

Answer: 4 Explanation: 1. Apical pulse rates should be obtained by auscultation for a full minute, preferably when the newborn is asleep. 2. Peripheral pulses of all extremities should also be evaluated to detect any inequalities or unusual characteristics. 3. Blood pressure in the lower extremities is usually higher than that in the upper extremities. 4. Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute.

The nurse is providing care to a postpartum client who is relinquishing custody of her newborn through an open adoption. Which nursing action is most important? 1. Assigning the client a room on the GYN surgical floor instead of the postpartum floor 2. Preparing to have teaching done in time for discharging the client at 24 hours postdelivery 3. Making an effort not to bring up the topic of the baby, and discuss the mother's health instead 4. Asking the client if she wants to feed her baby, and how much contact she wants to have

Answer: 4 Explanation: 1. Clients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead. 2. Not all clients who relinquish their infants want early discharge. Make no assumptions, but assess instead. 3. The client's preferences determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead. 4. Assess the client's preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother.

The nurse is planning the care of a 1-day-old infant. Which intervention would protect the newborn from heat loss by convection? 1. Drying the newborn thoroughly 2. Prewarming the examination table 3. Removing wet linens from the isolette 4. Placing the newborn away from air currents

Answer: 4 Explanation: 1. Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation. 2. Prewarming the examination table reduces heat loss by conduction. 3. Removing wet linens that are not in direct contact with the newborn from the isolette reduces heat loss by radiation. 4. Placing the newborn away from air currents reduces heat loss by convection.

The nurse notes that a 1-day-old infant's immunoglobulin M (IgM) antibodies are elevated. Which is the least likely cause for this elevation? 1. Placental leakage 2. Intrauterine exposure to syphilis 3. Intrauterine exposure to TORCH (toxoplasmosis, rubella, cytomegalovirus, herpesvirus hominis type 2 infection) syndrome 4. Maternal-fetal transfer of IgM while in utero

Answer: 4 Explanation: 1. Elevated levels of IgM at birth may indicate placental leaks. 2. Elevations in IgM may be due to newborn exposure to an intrauterine infection such as syphilis. 3. Elevations in IgM at birth may be due to newborn exposure to an intrauterine infection such as TORCH syndrome. 4. Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks' gestation.

A mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? 1. "Your baby must be dehydrated." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."

Answer: 4 Explanation: 1. Fontanelles can be depressed when the infant is dehydrated. 2. The posterior fontanelle closes within 8 to 12 weeks. This is a normal finding at 16 weeks, and does not require emergency evaluation. 3. Overriding of the cranial bones is referred to as molding, and will diminish within a few days following birth. 4. This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks.

The nurse is teaching a postpartum client when light housekeeping can be resumed. Which response by the client indicates accurate understanding of the information provided? 1. "I can resume light housekeeping after the 6-week postpartum checkup." 2. "I can resume light housekeeping during my first week at home." 3. "I can resume light housekeeping during my second day at home." 4. "I can resume light housekeeping after my second week at home."

Answer: 4 Explanation: 1. It is not necessary to wait until after the 6-week postpartum checkup to resume light housekeeping. 2. Within the first week is too early to resume even light housekeeping activity. 3. The second day is too early to resume even light housekeeping activity. 4. The postpartum client can resume light housekeeping after the second week at home.

What should the nurse assess to determine healing of the uterus at the placental site? 1. Laboratory values 2. Uterine size 3. Blood pressure 4. Type, amount, and consistency of lochia

Answer: 4 Explanation: 1. Laboratory values are too vague, since the actual values are not identified. 2. Uterine size alone is not enough to assess the placental site. 3. Blood pressure varies slightly in the normal postpartum client and would not affect the placental site. 4. Type, amount, and consistency of lochia determine the stage of healing of the placental site, which occurs by a process of exfoliation.

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How should the nurse document this finding? 1. Nevus flammeus 2. Nevus vasculosus 3. A Mongolian spot 4. Telangiectatic nevi

Answer: 4 Explanation: 1. Nevus flammeus (port-wine stain), a capillary angioma, is located directly below the epidermis. 2. Nevus vasculosus (strawberry mark) is a capillary hemangioma. 3. Mongolian spots are macular areas of bluish black pigmentation on the dorsal area of the buttocks. 4. 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.

The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness? 1. Normal newborn nursery centrally located to all client rooms 2. A kitchen with refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a client bed and rocking chair 4. A nursing model based on providing couplet care

Answer: 4 Explanation: 1. Rooming-in better promotes family wellness than does having newborns in the nursery. 2. Although having snacks is good for postpartum clients, some cultures prohibit drinking cold liquids after birth; warm liquids must also be available for optimal family wellness. 3. Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better. 4. Couplet care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered.

The nurse explains normal newborn behavior to new parents who are concerned about the baby's desire to be held. Which statement indicates that teaching has been effective? 1. "Some babies are easier to deal with than others." 2. "Our baby spends more time in the active alert phase." 3. "We are lucky to have a baby with a calm disposition." 4. "Cuddliness is a social behavior that some babies have."

Answer: 4 Explanation: 1. Saying a baby is easier or more difficult to deal with is a judgment, not an assessment. 2. The active alert phase of the sleep-wake cycle is characterized by motor activity. 3. Describing an infant as having a calm disposition is a judgment, not an assessment. 4. Cuddliness or social behaviors refers to the newborn's need for, and response to, being held.

Before the nurse begins to dry the newborn off after birth, which assessment finding should be documented to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Size of the areolae 2. Creases on the sole 3. Body surface temperature 4. Amount and area of vernix coverage

Answer: 4 Explanation: 1. Size of the areolae is not affected by drying of the newborn. 2. Creases on the sole are not affected by drying of the newborn. 3. Body surface temperature is not part of the Ballard gestational assessment tool. 4. Drying the baby after birth will disturb the vernix and potentially alter the score when using the Ballard gestational assessment tool. The nurse first should document the amount and coverage of the vernix before drying the newborn.

The nurse is assessing a newborn's musculoskeletal status. How should the nurse assess for clubfoot? 1. Stimulate the sole of the foot 2. Adduct the foot and listen for a click 3. Extend the foot and observe for pain 4. Move the foot to midline and determine resistance

Answer: 4 Explanation: 1. Stimulating the sole of the foot will elicit the plantar grasp reflex, and is not an appropriate assessment for clubfoot. 2. Adducting the foot and listening for a click is not an assessment that is done. 3. Extending the foot and observing for pain will not determine or rule out clubfoot. 4. Clubfoot is suspected when the foot will not turn to a midline position or align readily.

The nurse wants to demonstrate to a new family their infant's individuality. Which assessment tool should the nurse use? 1. Ortolani maneuver 2. Ballard Maturity Scale 3. Dubowitz Gestational Age Scale 4. Brazelton Neonatal Behavioral Assessment Scale

Answer: 4 Explanation: 1. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia. 2. The Ballard Maturity Scale is a tool that assesses external physical characteristics and neurologic or neuromuscular development. 3. The Dubowitz Gestational Age Scale is a tool that assesses external physical characteristics and neurologic or neuromuscular development. 4. The Brazelton Neonatal Behavioral Assessment Scale assesses the newborn's state changes, temperament, and individual behavior patterns.

The nurse is making an initial assessment of a newborn. Which data would be considered normal? 1. Chest circumference 30 cm, head circumference 29 cm 2. Chest circumference 38 cm, head circumference 31.5 cm 3. Chest circumference 32.5 cm, head circumference 38 cm 4. Chest circumference 31.5 cm, head circumference 33.5 cm

Answer: 4 Explanation: 1. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 2. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 3. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 4. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth.

A new mother is concerned about spoiling her newborn. Which statement should the home care nurse include in this teaching session with the new mother? 1. "Spoiling occurs when an infant is rocked to sleep every night." 2. "Newborns can be manipulative, so caution is advised." 3. "Crying is good for an infant, and letting them cry it out is advised." 4. "It is important to meet your infant's needs to develop a trusting relationship."

Answer: 4 Explanation: 1. The new mother should be taught that an infant cannot be spoiled, especially by rocking the infant to sleep each night. This statement is inappropriate for the nurse to include in the teaching session. 2. Newborns are not manipulative. This statement is inappropriate for the nurse to include in the teaching session. 3. An infant should not be allowed to "cry it out" because this does not meet the infant's needs to develop a trusting relationship. This statement is inappropriate for the nurse to include in the teaching session. 4. Meeting the infant's needs develops a trusting relationship. Picking babies up when they cry teaches them that adults try to meet their needs and are responsive to them. This helps build a sense of trust in humankind.

A new parent asks why the baby appears to be occasionally cross-eyed. When should the nurse instruct the parent that this finding will resolve? 1. 1 year 2. 2 weeks 3. 2 months 4. 4 months

Answer: 4 Explanation: 1. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. 2. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. 3. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. 4. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months.

The nurse is reviewing the medical records of several newborns. Which infant requires immediate intervention? 1. 24-hour-old term male with total bilirubin level of 2 2. 3-day-old term bottle-fed female with bilirubin of 11 3. 2-week-old postterm breastfed male with bilirubin of 10 4. 12-hour-old preterm female exhibiting icterus and lethargy

Answer: 4 Explanation: 1. Total bilirubin levels under 3 are expected in the first 24 hours of life. 2. Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11 is not treated with phototherapy, regardless of feeding method. 3. Breast milk jaundice peaks at 2 to 3 weeks of age and commonly presents with a total bilirubin level of 5 to 10. 4. Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice.

During a home care visit, the new breastfeeding mother reports breast engorgement. Which statement by the home care nurse is most appropriate based on this information? 1. "Apply an ice compress to your breast before nursing." 2. "Encourage your baby to suckle for an average of 5 minutes per feeding." 3. "Apply warm compresses to your breast after you finish feeding your baby." 4. "When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep."

Answer: 4 Explanation: 1. Warm, not ice, compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. 2. For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours. 3. Cool, not warm, compresses after nursing can help slow refilling of the breasts and provide comfort to the mother. 4. The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.

A newborn weighing 7.7 lb has an estimated bladder capacity of 20 mL. If 25 mL/kg of urine is expected to be produced each day, how many diaper changes will this baby need? (Calculate by rounding to the nearest whole number.)

Answer: 4 Explanation: First determine the baby's weight in kilograms by dividing 7.7 pounds by 2.2, or 7.7/2.2 = 3.5 kg. Then multiply the weight by 25 mL/kg = 25 × 3.5 = 87.5, which is the amount of urine produced by the newborn. Then divide the total amount of urine by the bladder capacity of 20 mL, or 87.5/20 = 4.375. With rounding, the baby will need an estimated 4 diaper changes each day.

Page Ref: 655 A postpartum client weighing 165 lb is prescribed to take 12 mg/kg/day of lysine to help with afterpains. If the client ingests 375 mg of lysine in food, how many additional milligrams of the supplement should the client take? (Calculate to the nearest whole number.)

Answer: 525 mg Explanation: First determine the client's weight in kilograms by dividing the weight in pounds by 2.2, or 165/2.2 = 75 kg. Then determine the amount of lysine that should be taken each day by multiplying the client's weight by 12, or 75 × 12 mg = 900 mg. If the client ingests 375 mg of lysine each day in food, then subtract this amount from the total amount of lysine, or 900 - 375 = 525 mg.

A newborn weighing 8.8 lb is prescribed bottle-feedings every 3 hours to achieve the caloric intake of 120 calories/kg each day. How many calories should be in each ounce of feeding? (Calculate to the nearest whole number.)

Answer: 60 calories Explanation: First determine the infant's weight in kilograms by dividing the weight in pounds by 2.2, or 8.8/2.2 = 4 kg. Then determine the total number of calories per day by multiplying 120 calories × 4 = 480. Then divide the total calories by 8 (feedings every 3 hours are determined by dividing 24 hours by 3 = 8), or 480/8 = 60 calories. Each feeding should provide the newborn with 60 calories.

A client weighing 80 kg lost 5 kg of body weight immediately after delivery. In 2 days, another 3 kg has been lost. During a 6-week postpartum examination the client was pleased to learn of returning to her prepregnancy weight of 143 lb. How many kilograms of weight did the client lose during the 6 weeks postpartum? (Calculate to the nearest whole number.)

Answer: 7 kg Explanation: First determine the client's starting weight in pounds by multiplying her weight in kilograms by 2.2, or 80 × 2.2 = 176. Then subtract the prepregnancy weight from the pregnancy weight, or 176 - 143 = 33 pounds. Then divide the weight in pounds by 2.2, or 33/2.2 = 15 kg. Then subtract the total number of kilograms lost after delivery from the total weight of 15 kg. or 15 kg - 5 kg - 3 kg = 7 kg. The client lost 7 kg of weight in 6 weeks.

14) The nurse documents that a postpartum client's volume of lochia is moderate. What did the nurse most likely assess to make this clinical determination? 1. 2. 3. 4.

Answer: About 3 inches of the pad and 1 inch wide, but not the whole pad. Explanation: This would be estimated as a moderate amount of lochia.

The nurse is assessing the abdomen of a client who delivered an infant 1 hour ago. On the abdomen, where should the nurse assess the client's uterine level?

Answer: In explanation. Explanation: Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus.

7) A 26-year-old multigravida who is 28 weeks pregnant and follows a program of regular exercise develops gestational diabetes. What instructions should be included in a teaching plan for this client? 1. "Carry hard candy (or other simple sugar) when exercising." 2. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." 3. "Exercise either just before meals or wait until 2 hours after a meal." 4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk."

1. A client should be encouraged to continue any exercise programs in which she already is involved. She should keep hard candy (simple sugar) with her at all times, just in case the exercise induces hypoglycemia. Page Ref: 274

13) During the first antepartal visit, a client who is at 10 weeks' gestation learns of being HIV positive. Which client statement indicates an understanding of the plan of care both during the pregnancy and postpartally? 1. "I should not breastfeed my baby." 2. "When my baby is 2 months old, he or she will be tested for HIV." 3. "If I have a cesarean section, there is an increased risk that my HIV will be passed to my baby." 4. "I am supposed to take highly active antiretroviral therapy (HAART), but only during the first trimester."

1. HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth. Page Ref: 286

Answer: 3 Explanation: 1. This is less than recommended for a twin-gestation pregnancy. 2. This is less than recommended for a twin-gestation pregnancy. 3. This is the recommended caloric and protein intake in a twin-gestation pregnancy. 4. This is recommended if the twins are underweight.

10) The nurse is counseling a newly pregnant gravida 1 at 8 weeks' gestation with twins about the need for increased caloric intake. What should the nurse emphasize as being the minimum recommended intake? 1. 2500 kcal and 120 g protein 2. 3000 kcal and 150 g protein 3. 3500 kcal and 175 g protein 4. 4000 kcal and 190 g protein

Answer: 1 Explanation: 1. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the client with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop. 2. Gestational diabetes can lead to polyhydramnios but does not cause oligohydramnios. 3. The risk of fetal demise is increased with oligohydramnios. Labor is usually induced when the client reaches term pregnancy to prevent fetal demise. 4. Oligohydramnios occurs in 1% to 3% of pregnancies. It rarely recurs in subsequent pregnancies.

12) A client at 38 weeks' gestation is diagnosed with oligohydramnios. Which statement indicates that teaching has been effective? 1. "When I go into labor, I should come to the hospital right away." 2. "My gestational diabetes may have caused this problem to develop." 3. "Women with this condition usually go into labor after their due date." 4. "This problem is common and will likely occur with my next pregnancy."

Answer: 4 Explanation: 1. An uncomplicated elective cerclage may be done as an outclient. 2. An emergency cerclage requires hospitalization for 5 to 7 days or longer. 3. After 37 completed weeks' gestation, the suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed. 4. Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure.

2) The clinical instructor reviews postoperative care of cerclage with a group of nursing students. Which student statement indicates the need for further information? 1. "Sometimes cerclage can be performed on an outclient basis." 2. "If cerclage is performed emergently, the client will usually be hospitalized for at least 5 days." 3. "After 37 weeks' gestation, the client's cerclage may be cut in order to allow for vaginal delivery." 4. "If the client's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed."

Answer: 2 Explanation: 1. Contractions are not associated with cervical insufficiency. 2. Cervical insufficiency is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix. 3. Cervical pain is not a manifestation of cervical insufficiency. 4. Contractions are not associated with cervical insufficiency.

3) A pregnant client is diagnosed with cervical insufficiency. How should the nurse expect this client to explain symptoms of this condition? 1. "I've been having contractions every 4 hours." 2. "I'm not having any pain and I do not feel any contractions." 3. "My cervical pain has gotten much worse over the past 2 days." 4. "I'm not having any pain, but my contractions are getting stronger."

12) A client at 9 weeks' gestation learns about being HIV positive. Which client statement indicates teaching about the effects on the baby has been effective? 1. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 2. "The HIV will not affect my baby, and I will have a low-risk pregnancy without additional testing." 3. "My baby will probably be born with anti-HIV antibodies, but that does not mean the baby is infected." 4. "I cannot take the medications that control HIV during my pregnancy because they will harm the baby."

3. Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV antibodies. HIV infection in infants should be diagnosed using HIV virologic assays as soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is positive. Page Ref: 281

16) A client at 24 weeks has a history of class II heart disease secondary to rheumatic fever. What should the nurse expect to see in the medical record? 1. Dyspnea and chest pain with mild exertion 2. Elective cesarean birth scheduled for 37 weeks 3. Discussed need for labor epidural and vacuum extraction 4. Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally

3. Lumbar epidural analgesia decreases the stress response during labor, while vacuum extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the heart during birth. Page Ref: 286

9) A pregnant client at 23 weeks' gestation has a hemoglobin of 9.5. Which diet choice indicates that teaching has been effective? 1. Broiled fish, lettuce salad, grapefruit half, carrot sticks 2. Pork chop, mashed potatoes and gravy, cauliflower, tea 3. Roast beef, steamed spinach, tomato soup, orange juice 4. Tofu with mixed vegetables in curry, milk, whole-wheat bun

3. This client is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells. Page Ref: 276

2) The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which client statement indicates that teaching has been effective? 1. "A beer once a week will not damage the fetus." 2. "I can continue to drink alcohol until I am diagnosed as being pregnant." 3. "I can drink alcohol while breastfeeding since it does not pass into breast milk." 4. "I need to stop drinking alcohol completely when I start trying to get pregnant."

4. Because birth defects that are related to fetal alcohol exposure can occur in the first 3 to 8 weeks' gestation, often before the woman even knows she is pregnant, women should discontinue drinking alcohol when they start to attempt pregnancy. Page Ref: 277

1) A pregnant client who uses cocaine and ecstasy on a regular basis asks why ecstasy should not be used during pregnancy. What should the nurse explain about this drug? 1. "It produces intrauterine growth restriction and meconium aspiration." 2. "It leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "It produces babies with small heads and short bodies with brain function alterations." 4. "It can cause a high fever in you if high doses are taken and therefore cause the baby harm."

4. High body temperature is a side effect of MDMA (methylenedioxymethamphetamine: ecstasy). Increased body temperature increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major organ damage. Page Ref: 278

5) The client with insulin-dependent type 2 diabetes and an HbA1c of 5% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client? 1. Vascular disease that accompanies diabetes slows progression. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. The baby is likely to have a congenital abnormality because of the diabetes. 4. Insulin needs decrease in the first trimester and increase during the third trimester.

4. In addition, insulin requirements drop suddenly after delivery of the placenta. Page Ref: 267

15) A pregnant woman married to an intravenous drug user had a negative HIV screening test just after missing her first menstrual period. What would indicate that the client needs to be retested for HIV? 1. Elevated blood pressure and ankle edema 2. Shortness of breath and frequent urination 3. Hemoglobin of 11 g/dL and a rapid weight gain 4. Unusual fatigue and recurring Candida vaginitis

4. The client who is HIV-positive would have a suppressed immune system and would experience symptoms of fatigue and opportunistic infections such as Candida vaginitis. Page Ref: 282

4) A 20-year-old woman at 28 weeks' gestation has a history of past drug abuse and her urine screening indicates recent heroin use. What should the nurse recognize this client is at risk for developing? 1. Diabetes mellitus 2. Abruptio placentae 3. Erythroblastosis fetalis 4. Pregnancy-induced hypertension

4. Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or preeclampsia). Page Ref: 278

A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed? 1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collar bone broken."

Answer: 1 Explanation: 1. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus. 2. Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk. 3. Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus. 4. Shoulder dystocia is more common among large fetuses, and a broken clavicle could result

22) A pregnant client is diagnosed with a cardiac problem. What should the nurse prepare to instruct this client to do, to ensure a safe pregnancy? Select all that apply. 1. Restrict activities. 2. Follow a diet high in iron and protein. 3. Restrict the intake of sodium. 4. Obtain 8 to 10 hours of sleep. 5. Obtain pneumococcal vaccination.

Answer: 1, 2, 3, 4 Explanation: 1. To help preserve her cardiac reserves, the woman may need to restrict her activities. 2. For the pregnant client with cardiac problems, the client should be instructed in the importance of a diet high in iron and protein. 3. For the pregnant client with cardiac problems, the client should be instructed in the importance of a diet low in sodium. 4. For the pregnant client with cardiac problems, 8 to 10 hours of sleep are essential. Page Ref: 286

15) A client at 40 weeks' gestation is being considered for cervical ripening. Which criteria should the nurse use to determine the client's success for induction? Select all that apply. 1. Position 2. Effacement 3. Consistency 4. Fetal heart rate 5. Cervical dilatation

Answer: 1, 2, 3, 5 Explanation: *1. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include position.* *2. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include effacement.* *3. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include consistency.* 4. A prelabor scoring system was developed that is helpful to predict the potential success of induction. The fetal heart rate is not a component that is evaluated. *5. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include cervical dilatation.*

The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time? 1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid.

Answer: 2 Explanation: 1. This assessment is not called for at this time. 2. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated. 3. Pain medication is a low priority at this time. 4. Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.

A newly admitted client at 32 weeks' gestation is experiencing a sudden onset of intense nausea and a frontal headache for the past 2 days. The client's initial blood pressure is 158/98, and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing? 1. Ordering a low-protein diet for the client 2. Conducting a urine dipstick test to assess for proteinuria 3. Placing a wedge under the client's left hip so that she is in a right lateral tilt position 4. Administering diuretics and facilitating a dietary regimen of strict sodium restriction

Answer: 2 Explanation: 1. This client's signs and symptoms are consistent with preeclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/day) to replace protein lost in the urine. 2. This client's signs and symptoms are consistent with preeclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria. 3. This client's signs and symptoms are consistent with preeclampsia. Appropriate interventions include instituting bed rest with the client positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion. 4. This client's signs and symptoms are consistent with preeclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating preeclampsia.

) A pregnant woman is being excavated from the back seat of a motor vehicle after a crash. In which order should this victim receive emergency care? 1. Apply oxygen. 2. Establish an airway. 3. Monitor fetal activity. 4. Position on the left side. 5. Administer intravenous fluids.

Answer: 2, 1, 5, 4, 3 Explanation: 1. Applying oxygen occurs after an airway is established. 2. The first action is to establish an airway. 3. Monitoring fetal activity occurs after the victim is stabilized. 4. Positioning on the left side helps prevent hypotension. 5. Intravenous fluids are provided to prevent shock and maintain circulation.

19) The nurse is concerned that a pregnant client is experiencing depression. Which potential health issues should the nurse include when planning care for this client? Select all that apply. 1. Alcohol use 2. Preterm birth 3. Poor appetite 4. Poor weight gain 5. Antenatal hemorrhage

Answer: 2, 3, 4 2. A pregnant client with depression is at risk for preterm birth. 3. A pregnant client with depression is at risk for poor appetite. 4. A pregnant client with depression is at risk for poor weight gain. Page Ref: 279

Which maternal-child client should the nurse see first? 1. Blood type B, Rh-positive 2. Blood type O, Rh-negative 3. Direct Coombs test positive 4. Indirect Coombs test negative

Answer: 3 Explanation: 1. This client's blood type creates no problems. 2. This client is Rh-negative, but there is no indication that the alloimmunization has occurred. 3. A direct Coombs test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and the baby is making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia. 4. An indirect Coombs test looks for Rh antibodies in the maternal serum; a negative result indicates the client has not been alloimmunized.

A client who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing? 1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM). 2. Obtain an antibody screen (indirect Coombs test) to determine whether the client has developed isoimmunity. 3 Note the potential for ABO incompatibility and plan to carefully assess the neonate for the development of hyperbilirubinemia. 4. Notify the primary care provider and document the potential need for treatment of fetal hemolytic anemia in the baby after delivery.

Answer: 3 Explanation: 1. RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood. 2. An antibody screen (indirect Coombs test) is done to determine whether an Rh-negative woman is sensitized (has developed isoimmunity) to the Rh antigen. 3. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment, however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert healthcare providers to the need for carefully assessing the newborn for the development of hyperbilirubinemia. 4. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia.

20) After completing a physical assessment the nurse determines that a laboring client is experiencing a panic attack. What findings did the nurse use to make this clinical determination? Select all that apply. 1. Flat affect 2. Monotone replies 3. Heart rate 120 bpm 4. Respiratory rate 28/minute 5. Disoriented to place and time

Answer: 3, 4 3. A heart rate of 120 bpm indicates tachycardia, a manifestation of a panic attack. 4. A respiratory rate of 28/minute indicates hyperventilation, a manifestation of a panic attack. Page Ref: 280