NCLEX questions, answers, rationals
Select the two most important nursing assessments immediately after a woman receives an epidural block. 1. Bladder distention 2. Condition of IV site 3. Respiratory rate 4. Blood pressure
1. Bladder distention 4. Blood pressure Rationale: The most common side effects of an epidural are maternal hypotension and urinary retention. After initiation of the epidural block, the fetal heart rate and blood pressure should be monitored and documented every 5 minutes for 15 minutes and then every 30 minutes for 1 hour. The nurse should palpate the suprapubic area for a full bladder every 2 hours or more often if a large quantity of IV solution was given.
Exercise during pregnancy should be practiced to achieve which of the following goals? 1. Maintaining physical fitness 2. Minimizing weight gain 3. Achieving weight loss 4. Improving physical fitness
1. Maintaining physical fitness Rationale: The goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight loss.
A woman delivered her newborn several hours previously, and her uterus remains soft and boggy. Which of the following medications should the nurse anticipate that the health care provider would prescribe to increase uterine tone and firm the uterus? (Select all that apply.) 1. Methylergonovine (Methergine) 2. Carboprost (Hemabate) 3. Magnesium sulfate 4. Oxytoxin (Pitocin)
1. Methylergonovine (Methergine) 2. Carboprost (Hemabate) 4. Oxytoxin (Pitocin) Rationale: A dilute oxytocin (Pitocin) IV infusion is the most common drug ordered to control uterine atony. Other drugs to increase uterine tone include methylergonovine (Methergine) or prostaglandins such as Hemabate or Cytotec. Magnesium sulfate is a tocolytic and relaxes the smooth muscle of the uterus.
Why are twins often born early? 1. The uterus becomes overdistended. 2. The placenta becomes distended. 3. The woman's body cannot tolerate the weight. 4. The fetuses become too large to deliver vaginally.
1. The uterus becomes overdistended. Rationale: Many twin or higher multiples are born prematurely because the uterus becomes overly distended and irritable.
Which of the following are agencies that focus on global health and development? Select all that apply. 1. World Health Organization 2. United Nations 3. National Institutes of Health 4. American Nurses Association
1. World Health Organization 2. United Nations Rationale: The NIH and ANA deal with local health issues within the United States while the WHO and United Nations deal with global health.
The health care provider gives magnesium sulfate intravenously to a woman with a diagnosis of preeclampsia. Which of the following nursing interventions are priority when caring for a patient who has received magnesium sulfate? (Select all that apply.) a. Monitor uterine tone. b. Monitor urine output. c. Keep patient NPO. d. Monitor respiratory rate. 1. a and b 2. c and d 3. b and d 4. a and c
1. a and b a. Monitor uterine tone. b. Monitor urine output. 2. c and d c. Keep patient NPO. d. Monitor respiratory rate. 4. a and c a. Monitor uterine tone. c. Keep patient NPO. Rationale: Priority nursing interventions for a patient receiving magnesium sulfate for preeclampsia include monitoring uterine muscle tone to assess for complications or signs of labor, as well as monitoring urine output and respiratory rate to assess for signs of toxicity. The woman receiving magnesium sulfate can have ice chips and sips of water during treatment.
A woman who is in the early first stage of labor asks how she can relieve her discomforts. The nurse knows that nonpharmacological techniques that can relieve discomforts include: a. sacral pressure b. effleurage c. sitz bath d. laxatives 1. a and b 2. c and d 3. a and d 4. b and c
1. a and b a. sacral pressure b. effleurage Rationale: Laxatives are not given during labor and a sitz bath is a measure to relieve perineal injury postpartum. Sacral pressure and effleurage are effective non-pharmacological pain-relief techniques during labor.
Nursing organizations that suggest standards of care in maternal-child nursing are: a. AWHONN b. ANA c. QSEN d. AAP 1. c and d 2. a and b 3. b and c 4. b and d
1. c and d c. QSEN d. AAP Rationale: QSEN has to do with delivering quality care; American Academy of Pediatrics (AAP) is managed by physicians who set standards for pediatric care delivered by physicians. AWHONN and ANA set standards for nursing care.
If a pregnant woman is admitted to the emergency department in shock after an accident, the nurse would help relieve the effect of shock by: a. placing her in Trendelenburg position b. placing her flat in bed in a supine position c. placing a small pillow under left hip d. closely observing and documenting fetal heart rate and contractions 1. c and d 2. a and d 3. b and d 4. d only
1. c and d c. placing a small pillow under left hip d. closely observing and documenting fetal heart rate and contractions Rationale: Placing a pregnant woman in supine or Trendelenburg's position places pressure on the uterine vessels and interferes with fetal circulation. Placing a small pillow under the left hip of the woman avoids this pressure. Close observation and documentation of the status of the mother and fetus is essential in all situations.
A woman who has gestational trophoblastic disease (hydatidiform mole) should continue to receive follow-up medical care after initial treatment because: 1. choriocarcinoma sometimes occurs after intial treatment. 2. she has lower levels of immune factors and is vulnerable to infection. 3. anemia complications most cases of hydatidiform mole. 4. permanent elevation of her blood pressure is more likely.
1. choriocarcinoma sometimes occurs after intial treatment. Rationale: Hydatidiform mole may cause hemorrhage, clotting abnormalities, hypertension, and later development of cancer (choriocarcinoma).
A woman in active labor has contractions every 3 minutes lasting 60 seconds, and her uterus relaxes between contractions. The electronic fetal monitor shows the FHR reaching 90 beats/min for periods lasting 20 seconds during a uterine contraction. The appropriate priority nursing action is to: 1. continue to monitor closely. 2. administer oxygen by mask at 10 L/min. 3. notify the health care provider. 4. prepare for a cesarean section.
1. continue to monitor closely. Rationale: Contractions every 3 minutes that last 60 seconds, a uterus that relaxes between contractions, and an FHR of 90 beats/minute that lasts 20 seconds during a uterine contraction all describe early decelerations, which result from compression of the fetal head and are a reassuring sign of fetal well-being.
The best way to maintain the newborn's temperature immediately after birth is to: 1. dry the newborn thoroughly, including the hair. 2. give the newborn a bath using warm water. 3. feed 1 to 2 ounces of warmed formula. 4. limit the length of time that parents hold the newborn.
1. dry the newborn thoroughly, including the hair. Rationale: Newborns lose heat quickly after birth because amniotic fluid evaporates from their bodies, drafts move heat away, and they may contact cold surfaces. Evaporation is a mechanism of heat loss, and the amniotic fluid evaporates from the newborn's wet skin. Interventions to prevent heat loss from evaporation include drying the infant quickly and drying and covering the infant's head.
During the postpartum period the white blood cell (leukocyte) count is normally: 1. higher than normal. 2. lower than normal. 3. unchanged. 4. unimportant.
1. higher than normal. Rationale: White blood cells (leukocytes) are normally elevated during the early postpartum period to about 20,000 to 30,000 cells/dL, which limits the usefulness of the blood count to identify infection. Leukocyte counts in the upper limits are more likely to be associated with infection than lower counts.
Excessive anxiety and fear during labor may result in a(n): 1. ineffective labor pattern. 2. abnormal fetal presentation or position. 3. release of oxytocin from the pituitary gland. 4. rapid labor and uncontrolled birth.
1. ineffective labor pattern. Rationale: Anxiety can increase a woman's perception of pain and reduce her tolerance of it. Anxiety and fear also cause the secretion of stress compounds from the adrenal glands. These compounds, called catecholamines, inhibit uterine contractions and divert blood flow from the placenta.
A woman who wants to become pregnant should avoid all medications unless they are prescribed by a physician who knows she is pregnant because: 1. the placenta allows most medications to cross into the fetus. 2. medications often have adverse effects when taken during pregnancy. 3. fetal growth is likely to be slowed by many medications. 4. the pregnancy is likely to be prolonged by some medications.
1. the placenta allows most medications to cross into the fetus. Rationale: The thin placental membrane provides some protection, but it is not a barrier to most substances ingested by the mother. Many harmful substances such as drugs, nicotine, and viral infectious agents are transferred to the fetus and may cause fetal drug addiction, congenital anomalies, and fetal infection.
A woman can keep a diary of her menstrual cycles to help determine her fertile period. She understands that after ovulation she will remain fertile for: 1. 2 hours. 2. 24 hours. 3. 3 to 5 days. 4. 7 to 14 days.
2. 24 hours. Rationale: The egg lives for only 24 hours after ovulation; therefore it is viable for fertilization only for 24 hours.
Which of the following organizations sets standards of practice for nursing? 1. American Medical Association (AMA) 2. American Nurses Association (ANA) 3. Utilization review committee 4. American Academy of Pediatrics (AAP)
2. American Nurses Association (ANA) Rationale:The ANA develops standards of practice. The AMA is a medical association that is geared toward physicians. Utilization review committee reviews appropriateness of health care services and guidelines for physicians for treatment of illness, controlling management of care to achieve cost containment. The AAP is made up of pediatricians and establishes positions of leadership in setting standards of care for children.
Which technique is likely to be most effective for back labor? 1. Stimulating the abdomen by effleurage 2. Applying firm pressure in the sacral area 3. Blowing out in short breaths during each contraction 4. Rocking from side to side at the peak of each contraction
2. Applying firm pressure in the sacral area Rationale: Firm pressure against the lower back helps relieve some pain from back labor. Effleurage is performed on the abdomen in a circular movement during contractions. Blowing out prevents pushing before full dilation is reached. Rocking from side to side will not relieve back labor discomfort.
Which assessments are expected 24 hours after birth? (Select all that apply.) 1. Scant amount of lochia alba on the perineal pad. 2. Fundus firm and in the midline of the abdomen. 3. Breasts distended and hard with flat nipples. 4. Bradycardia.
2. Fundus firm and in the midline of the abdomen. Rationale: After 24 hours, the fundus begins to descend about 1 cm (one finger's width) each day.
Which of the following is most appropriately used for pain relief during labor when the cervix is dilated less than 4 cm? 1. Naloxone (Narcan) via IM route 2. Meperidine (Demerol) via IM route 3. Promethazine (Phenergan) via IM route 4. Fentanyl (Sublimaze) via epidural route
2. Meperidine (Demerol) via IM route Rationale: Demerol (meperidine) along with Nubain is appropriate pain medication to use prior to 4 cm dilation. Epidurals are not usually given before 4 cm dilation. Phenergan is not given for pain relief.
Select the primary difference between the symptoms of placenta previa and abruptio placentae. 1. Fetal presentation 2. Presence of pain 3. Abnormal blood clotting 4. Presence of bleeding
2. Presence of pain Rationale: Manifestations of placenta previa include painless vaginal bleeding that is usually bright red. Bleeding accompanied by abdominal or low back pain is a typical characteristic of abruptio placentae.
Which of the following is a nursing intervention that does not require the written order of the health care provider? (Select all that apply.) 1. Administer an analgesic for pain. 2. Teach the patient how to perform perineal care. 3. Apply topical anesthetic for perineal suture pain. 4. Turn patient q2h.
2. Teach the patient how to perform perineal care. 4. Turn patient q2h. Rationale: Teaching the patient how to perform perineal care and turning the patient do not require a physician's order. Administration of analgesics and topical anesthetics would require a physician's order for implementation.
Which data indicate that a woman may have pelvic dimensions that would be inadequate for a normal vaginal delivery? A woman with a(n): 1. anthropoid-shaped pelvis with a history of pelvic inflammatory disease 2. gynecoid_shaped pelvis with a history of rickets 3. anthropoid-shaped pelvis that previously delivered a 9-lb infant 4. gynecoid-shaped pelvis with a history of poor nutrition
2. gynecoid_shaped pelvis with a history of rickets Rationale: Although the gynecoid-shaped pelvis is considered most favorable for a vaginal delivery, a woman with a history of rickets (a disease in which normal bone formation is disturbed when bone fails to mineralize and becomes soft and distorted) would be the most likely of the choices for inadequate normal vaginal delivery. An anthropoid-shaped pelvis with a history of PID, although not most favorable, allows for possible vaginal delivery, and history of PID might interfere with conception but not delivery. Previous delivery of a large infant is evidence of adequate pelvic dimensions for a normal vaginal delivery. Although poor maternal nutrition can affect the health of the newborn, delivery is not necessarily affected.
During a prenatal clinic visit, your intervention with an abused woman is successful if you have assessed the status of the woman and: 1. persuaded her to leave her abusive partner. 2. informed her of her safety options. 3. convinced her to notify the police. 4. placed her in a shelter for abused women.
2. informed her of her safety options. Rationale: The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The woman should be referred to local shelters for her safety. The decision to leave her abuser is hers.
A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. She repeatedly asks similar questions about what happened at birth. The nurse's interpretation of the woman's behavior is that she: 1. cannot accept that she did not have the type of delivery planned. 2. is trying to understand her experience and move on with postpartum adaptation. 3. thinks the staff is not telling her the truth about what happened at birth. 4. is confused about events because the effects of the general anesthetic are persisting.
2. is trying to understand her experience and move on with postpartum adaptation. Rationale: The nurse answers questions about events surrounding the birth and should encourage the woman and her partner to talk about the birthing situation so that they can integrate the experience. The focus should be on the birth rather than on the surgical aspects of cesarean delivery.
A laboring woman suddenly begins making grunting sounds and bearing down during a strong contraction. The nurse should initially: 1. leave the room to find an experienced nurse to assess the woman. 2. look at her perineum for increased bloody show or perineal bulging. 3. ask her if she needs pain medication. 4. tell her that these are common sensations in late labor.
2. look at her perineum for increased bloody show or perineal bulging. Rationale: Grunting sounds and bearing down suggest that the woman is about to give birth. The nurse must stay with the woman and observe for other signs of impending birth, such as increased bloody show or perineal bulging, as well as monitor maternal and fetal well-being. The nurse may use the call bell to summon assistance or request the physician.
The muscular layer of the uterus that is the functional unit in pregnancy and labor is the: 1. perimetrium 2. myometrium 3. endometrium 4. cervix
2. myometrium Rationale: The myometrium is the middle muscular uterine layer and is functional in pregnancy and labor. The perimetrium is the outermost, or serosal, layer that envelops the uterus. The endometrium is the inner, or mucosal, layer that is functional during menstruation and implantation of the fertilized ovum. The cervix is the lower part of the uterus that lubricates the vagina, acts as a bacteriostatic agent, provides an alkaline environment, and produces a mucous plug.
The earliest finding in postpartum hypovolemic shock is usually: 1. low blood pressure. 2. rapid pulse rate. 3. pale skin color. 4. soft uterus.
2. rapid pulse rate. Rationale: Tachycardia (rapid heart rate) is usually the first sign of inadequate blood volume (hypovolemia). The first blood pressure change is a narrow pulse pressure (a falling systolic pressure and a rising diastolic pressure). Skin and mucous membrane changes occur after tachycardia.
Spermatozoa are produced in the: 1. vas deferens. 2. seminiferous tubules. 3. prostate gland. 4. Leydig cells.
2. seminiferous tubules. Rationale: Sperm are made in the convoluted seminiferous tubules of the testes. The other answer options are not correct because sperm are produced only in the testes.
A woman's LNMP was on April 1, 2019. She has been keeping her prenatal clinic appointments regularly but states she needs to alter the dates of a future appointment because she and her husband are going on an ocean cruise vacation for the New Year's celebration from December 30 through January 7, 2020. The best response of the nurse would be: 1. "Prenatal visits can never be altered. Every visit is important." 2. "Be sure to take antinausea medication when going on an ocean cruise." 3. "Perhaps you might consider rescheduling your vacation around the Thanksgiving holiday rather than the New Year's dates." 4. "I will reschedule your clinic appointment to accommodate your vacation plans.
3. "Perhaps you might consider rescheduling your vacation around the Thanksgiving holiday rather than the New Year's dates." Rationale: The woman's EDC (estimated date of confinement), using Naegele's rule, is calculated to be January 8, 2014. Scheduling a vacation that ends one day prior to the due date should be discouraged. Suggesting that the vacation be rescheduled is the best response by the nurse.
The nurse can anticipate that which of the following patients may be scheduled for induction of labor? A woman who is: 1. 38 weeks' gestation with fetus in transverse lie. 2. 40 weeks' gestation with fetal macrosomia. 3. 40 weeks' gestation with gestational hypertension. 4. 40 weeks' gestation with a fetal prolapsed cord.
3. 40 weeks' gestation with gestational hypertension. Rationale: Labor is induced if continuing the pregnancy is hazardous for the woman or the fetus. An indication for labor induction is gestational hypertension. Risk factors are too great for induction in the other choices.
A woman in labor states she wants to have epidural analgesia. When can this method of analgesia best be given? 1. Anytime during labor 2. During the transition phase of labor 3. During the first stage of labor 4. During the third stage of labor
3. During the first stage of labor Rationale: An epidural block is best given during the first stage of labor after the patient is 3 cm dilated and preferably before 7 cm of dilation. Timing of epidural insertion is essential because if it is inserted too early, it can slow down labor, and if it is inserted too late, it can interfere with the woman's ability to push effectively. Although transition is in the first stage of labor, it is usually the shortest phase. The third stage of labor is delivery of the placenta.
The nurse is caring for a woman in labor. Which of the following observations require immediate nursing intervention? a. FHR of 90 beats/min between contractions b. maternal tachysystole c. contractions lasting 60 seconds with an interval of 90 seconds d. FHR baseline variability 1. b and c 2. a and d 3. a and b 4. c and d
3. a and b a. FHR of 90 beats/min between contractions b. maternal tachysystole Rationale: Fetal heart baseline variability is normal and contractions lasting 60 seconds with an interval of 90 seconds allow for adequate fetal circulation, and no change in nursing care is indicated. A FHR below 110 indicates fetal distress and maternal tachysystole indicates the uterine contractions are compromising fetal circulation and both require immediate intervention.
A nurse is explaining probable signs of pregnancy to a group of women. Probable signs of pregnancy include: a. fetal heart beat b. abdominal striae c. amenorrhea d. Braxton Hicks contractions 1. a and c 2. c and d 3. b and d 4. a and d
3. b and d b. abdominal striae d. Braxton Hicks contractions Rationale: Abdominal striae can be caused by stretching muscles due to weight gain and abdominal pain can be caused by gastrointestinal issues and both mistaken for signs of pregnancy. Absence of the menstrual period and the presence of a fetal heart beat are likely caused by pregnancy.
The nurse is responsible to examine the umbilical cord of the newborn infant. The nurse knows that: a. the umbilical cord has 2 veins and 1 artery b. the umbilical cord has 2 arteries and 1 vein c. the umbilical cord has 2 arteries and 2 veins d. umbilical arteries carry blood away from the fetus e. umbilical arteries carry blood to the fetus 1. a and e 2. b and e 3. b and d 4. c and d
3. b and d b. the umbilical cord has 2 arteries and 1 vein d. umbilical arteries carry blood away from the fetus Rationale: The arteries and vein in the umbilical cord of the fetus function differently than arteries and veins in the rest of the body.
The nurse is leading a class discussing ovulation and menstruation. The nurse explains that ovulation occurs: a. 14 days after the last menstrual period b. 14 days before the next menstrual period c. at the 16th day of a 32-day menstrual cycle d. 1 week before menses occurs 1. b and d 2. a and c 3. b only 4. d only
3. b only Rationale: Options A and C are related to the midcycle of menstruation when the egg matures and are released.
To determine the frequency of uterine contractions, the nurse should note the time from the: 1. beginning to end of the same contraction. 2. end of one contraction to the beginning of the next contraction. 3. beginning of one contraction to the beginning of the next contraction. 4. contraction's peak until the contraction begins to relax.
3. beginning of one contraction to the beginning of the next contraction. Rationale: Frequency is the time it takes from the beginning of one contraction to the beginning of the next contraction. Duration is from the beginning to the end of the same contraction. Interval is from the end of one contraction to the beginning of the next contraction.
A bleeding laceration is typically manifested by: 1. a soft uterus that is difficult to locate. 2. low pulse rate and blood pressure. 3. bright red bleeding and a firm uterus. 4. profuse dark red bleeding and large clots.
3. bright red bleeding and a firm uterus. Rationale: Blood lost in lacerations is usually a brighter red than lochia, and it flows in a continuous trickle. Typically, the uterus is firm.
Following a vacuum extraction delivery, the nurse notices the newborn's head is not symmetrical with a chignon over the posterior fontanelle . The appropriate nursing action would be to: a. apply cold compresses to the swollen area b. notify the charge nurse or health care provider c. document and continue routine observation d. explain to the parents the swelling will resolve without treatment 1. a and b 2. a and c 3. c and d 4. all of the above
3. c and d c. document and continue routine observation d. explain to the parents the swelling will resolve without treatment Rationale: The vacuum extractor causes a harmless area of circular edema on the infant's scalp (chignon) where it was applied, does not necessitate intervention, and resolves quickly.
Nursing the newborn promotes uterine involution because it: 1. uses maternal fat stores accumulated during pregnancy. 2. stimulates additional secretion of colostrum. 3. causes the pituitary to secrete oxytocin to contract the uterus. 4. promotes maternal formation of antibodies.
3. causes the pituitary to secrete oxytocin to contract the uterus. Rationale: Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, a hormone that contracts the uterus.
A woman who is pregnant with her first child phones an intrapartum facility and says her "water broke." The nurse should tell her to: 1. wait until she has contractions every 5 minutes for 1 hour. 2. take her temperature every 4 hours and come to the facility if it is over 38 degrees C (100.4 degrees F). 3. come to the facility promptly, but safely. 4. call an ambulance to bring her to the facility.
3. come to the facility promptly, but safely. Rationale: When the amniotic sac ruptures, infection can become more likely if many hours elapse between the rupture of membranes and birth. In addition, the umbilical cord may slip down and become compressed. For these reasons, women should go to the birth facility when their membranes rupture, even if there are no other signs of labor.
A postpartum mother who is breastfeeding has developed mastitis. She states that she does not think it is good for her infant to drink milk from her infected breast. The best response from the nurse would be to: 1. instruct her to nurse the infant from only the unaffected breast until the infection clears up. 2. suggest that she discontinue breastfeeding and start the infant on formula. 3. encourage breastfeeding the infant to prevent engorgement. 4. apply tight breast binder to the infected breast until the infection subsides.
3. encourage breastfeeding the infant to prevent engorgement. Rationale: Antibiotics and continued removal of milk from the breast are the primary treatments for mastitis. The mother can usually continue to breastfeed unless an abscess forms.
A woman is being observed in the hospital because her membranes ruptured at 30 weeks gestation. While providing morning care, the nurse student notices that the draining fluid has a strong odor. The priority nursing action is to: 1. caution the woman to remain in bed until her physician visits. 2. ask the woman if she is having any more contractions than usual. 3. take the woman's temperature; report it and the fluid odor to the RN. 4. help to prepare the woman for an immediate cesarean delivery.
3. take the woman's temperature; report it and the fluid odor to the RN. Rationale: Amniotic fluid should be clear, possibly with flecks of vernix, and should not have a bad odor. The nurse should take the woman's temperature every 2 to 4 hours after her membranes rupture and observe, document, and report maternal temperature above 38° C (100.4° F), fetal tachycardia, tenderness over the uterine area, and foul-smelling fluid. These symptoms are suggestive of infection. A vaginal or cervical infection may cause membranes to rupture prematurely.
During a prenatal clinic visit, a woman states that she probably will not plan to breastfeed her infant because she has very small breasts and believes she cannot provide adequate milk for a full-term infant, The best response of the nurse would be: 1. "Ask the physician if he or she will prescribe hormones to build up the breasts." 2. "I can provide you with exercises that will build up your breast tissue." 3. "The fluid intake of the mother will determine the milk output." 4. "The size of the breast has no relationship to the ability to produce adequate milk."
4. "The size of the breast has no relationship to the ability to produce adequate milk." Rationale: Breast size is primarily determined by the amount of fatty tissue and is unrelated to a woman's ability to produce milk. The other answer options are inaccurate.
Which nursing action is the priority when a patient arrives at the clinic? 1. Prepare a plan of care. 2. Select the appropriate nursing diagnoses. 3. Administer medications as ordered. 4. Determine and document history and vital signs.
4. Determine and document history and vital signs. Rationale: Assessment is the first step of the nursing process and includes the collection of subjective and objective patient data. Diagnosis is the second step of the nursing process. Preparing a plan of care refers to the fourth step: planning. Administering medications relates to implementation, which is the fifth step of the nursing process.
What nursing intervention during labor can increase space in the woman's pelvis? 1. Promote adequate fluid intake. 2. Position her on the left side. 3. Assist her to take a shower. 4. Encourage regular urination.
4. Encourage regular urination. Rationale: The most common soft-tissue obstruction during labor is a full bladder. The health care provider encourages urination and may catheterize a woman in labor. These interventions prevent trauma to her bladder and make more room in her pelvis.
A woman has an incomplete abortion followed by vacuum aspiration. She is now in the recovery room with her husband and is crying softly. Select the most appropriate nursing action. 1. Leave the couple alone except for necessary recovery-room care. 2. Tell the couple that most abortions are for the best because the infant would have been abnormal. 3. Tell the couple that spontaneous abortion is very common and does not mean that they cannot have other children. 4. Express your regret at their loss and remain nearby if they want to talk about it.
4. Express your regret at their loss and remain nearby if they want to talk about it. Rationale: The woman experiencing abortion needs the nurse to listen and acknowledge the grief she and her partner feel. Open communication techniques such as providing a quiet presence, expressing sympathy, making open-ended statements, and providing reflection can accomplish this goal.
A woman arrives in the clinic for her prenatal visit. She states that she is currently 28 weeks pregnant with twins, she has a 5-year old son who was delivered at 39 weeks gestation and a 3-year old daughter delivered at 34 weeks gestation, and her last pregnancy terminated at 16 weeks gestation. The nurse will interpret her obstetric history as: 1. G4 T2 P2 A1 L4 2. G3 T2 P0 A1 L2 3. G3 T1 P1 A1 L2 4. G4 T1 P1 A1 L2
4. G4 T1 P1 A1 L2 Rationale: G stands for gravida or how many pregnancies the woman has had. In this scenario there is a history of four pregnancies. The TPALM system is used to describe parity. T stands for term; this woman has had one child delivered at 39 weeks, which is considered term. P stands for preterm; this woman has had one child delivered at 34 weeks' gestation, which is considered preterm. A stands for abortion; this woman reports a pregnancy that terminated at 16 weeks' gestation. L stands for living; this woman has two living children. M stands for multiple, which is optional and not provided as a choice in this question.
The nurse notes that a woman's contractions during oxytocin induction labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. What action is expected based on these assessments? 1. No action is expected; the contractions are normal. 2. The rate of oxytocin administration will be increased slightly. 3. Pain medication or an epidural block will be offered. 4. Infusion of oxytocin will be stopped.
4. Infusion of oxytocin will be stopped. Rationale: Oxytocin is discontinued, or its rate reduced, if signs of fetal compromise or excessive uterine contractions occur. Excessive uterine contractions are most often evidenced by contractions closer than every 2 minutes, durations longer than 90 seconds, or resting intervals shorter than 60 seconds.
What drug should be immediately available for emergency use when a woman receives narcotics during labor? 1. Fentanyl (Sublimaze) 2. Diphenhydramine (Benadryl) 3. Lidocaine (Xylocaine) 4. Naloxone (Narcan)
4. Naloxone (Narcan) Rationale: Naloxone (Narcan) is used to reverse respiratory depression caused by opioid drugs.
which source would the nurse use to determine whether a specific nursing activity is within the scope of practice on an LPN/LVN? 1.Doctor's prescription record 2. Nursing procedure manual 3. Head nurse or nurse manager 4. The nurse practice act
4. The nurse practice act Rationale: Specific activities are listed by the state nurse practice act and nurses must practice within the limitations of the nurse practice act for their state. The other answer options are not sources that determine scope of practice.
The nurse should be alert to subinvolution of the uterus as a cause of late postpartum bleeding. Signs to report and document include (select all that apply): a. fundal height higher than expected for date b. persistence of lochia rubra c. low blood pressure d. persistene of lochia rubra 1. c and d 2. a and d 3. a and b 4. b and c
4. b and c b. persistence of lochia rubra c. low blood pressure Rationale: Lochia rubra should only last for 3 days and prolonged lochia rubra may indicated subinvolution and low blood pressure may indicate loss of blood. Lochia alba does not occur in subinvolution and postpartum fundal height is not usually palpable in late postpartum bleeding.
The nurse is providing evidence-based care when he or she: 1. adheres to hospital procedures book guidelines. 2. carries out protocols learned in nursing school. 3. carries out the practice requested by the charge nurse or health care provider. 4. knows that the practice has been published in a professional journal or text.
4. knows that the practice has been published in a professional journal or text. Rationale: Evidence-based practice starts when the nurse uses the best evidence obtained from current, valid, published research. When the nurse combines that information with his or her critical thinking process, experiences, and patients' needs, it is then possible to plan safe, effective nursing care for the patient. The other answer options are not accurate.
The number of deaths of infants younger than 28 days of age per 1000 live births is termed the: 1. infant death rate. 2. neonatal birth rate. 3. neonatal morbidity rate. 4. neonatal mortality rate.
4. neonatal mortality rate. Rationale: Neonatal mortality rate is defined as the number of deaths of infants under age 1 year per 1000 live births. Birth rate and neonatal birth rate refer to the number of births per 1000 population in a year. Neonatal morbidity rate refers to illness.
The purpose of the foramen ovale is to: 1. increase fetal blood flow to the lungs. 2. limit blood flow to the liver. 3. raise the oxygen content of fetal blood. 4. reduce blood flow to the lungs.
4. reduce blood flow to the lungs. Rationale: The foramen ovale diverts most blood from the right atrium directly to the left atrium, rather than circulating it to the lungs. Therefore, blood flow to the lungs is reduced.
The child's sex is determined by the: 1. dominance of either the X or the Y chromosome. 2. number of X chromosomes in the ovum. 3. ovum, which contributes either an X or a Y chromosome. 4. sperm, which contains either an X or a Y chromosome.
4. sperm, which contains either an X or a Y chromosome. Rationale: The ovum always contributes an X chromosome (gamete), but the sperm can carry an X or a Y chromosome (gamete).
Eight hours postpartum the woman states she prefers the nurse to take care of the infant. The woman talks in detail about her birthing experience on the phone and to anyone who enters her room. She complains of being hungry, thirsty, and sleepy and is unable to focus on the infant care teaching offered to her. The nurse would interpret this behavior as: 1. inability to bond with the newborn. 2. development of postpartum psychosis. 3. inability to assume the parenting role. 4. the normal taking-in phase of the puerperium.
4. the normal taking-in phase of the puerperium. Rationale: Rubin described three phases of postpartum change that have been a framework of nursing care for 35 years. More recent studies have found that women progress through the same three phases. The first phase is "taking in." The mother is passive and willing to let others do for her. Conversation centers on her birth experience. The mother has an interest in her infant but is willing to let others handle the care and has little interest in learning. The primary focus is on recovery from birth and her need for food, fluids, and deep, restorative sleep.
A woman being seen for her first prenatal care appointment has a positive home pregnancy test, and her chart shows a TPALM recording of 40120. The nurse would anticipate that: 1. minimal prenatal teaching will be required because this is her fourth pregnancy. 2. the woman will need help in planning the care of her other children at home during her labor and delivery. 3. the woman should experience minimal anxiety because she is familiar with the progress of pregnancy. 4. this pregnancy will be considered high risk, and measures to reduce anxiety will be needed.
4. this pregnancy will be considered high risk, and measures to reduce anxiety will be needed. Rationale: According to the TPALM system, these numbers indicate that the woman has had 4 children at term, has had 0 children at preterm, has 2 children now living, and has had 0 multiples. Because it is indicated that she had 4 children at term but only 2 are living now, the system indicates this pregnancy would be high risk, and anxiety-reduction techniques will be required.
During a prenatal examination at 30 weeks gestation, a woman is lying on her back on the examining table. She suddenly complains of dizziness and feeling faint. The most appropriate response of the nurse would be to: 1. reassure the woman and take measures to reduce her anxiety level. 2. offer the woman some orange juice or other rapidly absorbed form of glucose. 3. place a pillow under the woman's head. 4. turn the woman onto her side.
4. turn the woman onto her side. Rationale: Displacing the uterus to one side by turning the patient (preferably to the left) is all that is needed to relieve the pressure. If the woman must remain flat for any reason, then a small towel roll placed under one hip will also help prevent supine hypotension.
When a couple has unprotected sexual intercourse 3 days before the woman ovulates, the risk of the woman becoming pregnant is: 1. limited because the ova lives only for 24 hours. 2. very high because both the ova and the sperm are capable of fertilizing at that time. 3. unknown. 4. very low because that is not the woman's "fertile period."
4. very low because that is not the woman's "fertile period." Rationale: The time during which fertilization can occur is brief because of the short life span of mature gametes. The ovum is estimated to survive for up to 24 hours after ovulation. The sperm remains capable of fertilizing the ovum for up to 5 days after being ejaculated into the area of the cervix. Therefore, the risk of pregnancy when unprotected intercourse occurs 4 days prior to ovulation is very low, because this is not the woman's fertile period.