NUR 114 Test 2 adaptive quiz

During a routine yearly physical, an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be? 1. "Let's discuss this concern a little more." 2. "Be sure to tell your primary healthcare provider about this problem." 3. "There is medication available for erectile dysfunction." 4. "This is an expected physiologic response to getting older."

1. "Let's discuss this concern a little more." "Let's discuss this concern a little more" communicates to the client that the nurse is willing and able to explore this concern. It is an open-ended statement that allows the client to control the direction of the conversation. By saying, "Be sure to tell your primary healthcare provider about this problem," the nurse abdicates responsibility to the primary healthcare provider. The nurse is capable of and legally responsible for collecting information and exploring the client's feelings and concerns. The response "There is medication available for erectile dysfunction" is premature; it moves immediately to a solution before adequate information has been collected. Also, the term erectile dysfunction is related to a medical diagnosis and its use at this time may increase client anxiety. Although sexual function diminishes as men age, many other factors (e.g., physiologic problems, interpersonal conflicts, emotional stress) also influence sexual function.

What client response must the nurse monitor to determine the effectiveness of amiodarone? 1. Absence of ischemic chest pain 2. Decrease in cardiac dysrhythmias 3. Improvement in fasting lipid profile 4. Maintenance of blood pressure control

2. Decrease in cardiac dysrhythmias Amiodarone is a class III antidysrhythmic used for treating ventricular and supraventricular tachycardia and for conversion of atrial fibrillation. Results of fasting lipid profile are expected with antilipidemics. Degree of blood pressure control is expected with antihypertensives. Incidence of ischemic chest pain is expected with antianginal agents, such as nitrates.

The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage? 1. Preeclampsia 2. Multifetal pregnancy 3. Prolonged first-stage labor 4. Cephalopelvic disproportion

2. Multifetal pregnancy The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.

During a routine prenatal visit, a client listens to the fetal heartbeat with the healthcare provider for the first time during her first trimester. The fetal heart rate is 150 beats/minute (bpm). The client looks frightened and asks whether this is normal. How should the nurse respond? 1. "Normal range for fetal heart rate at 12 weeks gestation is 120 to 180 bpm." 2. "Fetal average heart rate can be determined by multiplying the mother's heart rate times two." 3. "A slow fetal heart rate is more concerning than a rapid heart rate." 4. "A rapid fetal heart rate is necessary to meet nutritional needs."

1. "Normal range for fetal heart rate at 12 weeks gestation is 120 to 180 bpm." During the first trimester (1 to 12 weeks), the normal fetal heart rate is 120 to 180 bpm. The nurse should reassure the client. The normal heart rate for a fetus is not twice the mother's heart rate. There is no correlation between the fetal and maternal heart rates. Stating what is more concerning does not dismiss or validate the client's concerns. Fetal heart rate is not directly related to the nutritional needs of the fetus.

Which intervention does the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes? 1. Fast-acting insulin 2. Special high-risk care 3. Routine newborn care 4. Limited glucose intake

2. Special high-risk care The infant of a diabetic mother is a newborn at risk because of the interaction between the maternal disease and the developing fetus. The newborn of a mother with type 1 diabetes generally is hypoglycemic because of oversecretion of insulin by the newborn's hypertrophied pancreas. The newborn of a mother with type 1 diabetes is at high risk and requires intensive care. The newborn of a mother with type 1 diabetes is prone to hypoglycemia and will probably need increased glucose.

The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply. 1. The newborn has a flat abdomen. 2. The newborn weighs 6 lbs (2,700 g). 3. The newborn's hands and feet appear cyanosed. 4. The newborn does not blink in the presence of light. 5. The circumference of the head is 33 cm (13 in).

2. The newborn weighs 6 lbs (2,700 g). 3. The newborn's hands and feet appear cyanosed. 5. The circumference of the head is 33 cm (13 in). The average newborn weighs between six to nine pounds (2,700 to 4,000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.

Which nursing intervention holds the highest priority for a client with class I heart disease during the postpartum period? 1. Promoting early ambulation 2. Watching for signs of cardiac decompensation 3. Assessing the mother's emotional reaction to the birth 4. Instructing the mother about activity levels during the postpartum period

2. Watching for signs of cardiac decompensation Cardiac decompensation may occur because of the increased circulating blood volume during the early postpartum period, which requires increased cardiac function. Although promotion of early ambulation, assessing the mother's emotional reaction to the birth, and instructing the mother regarding activity during the postpartum period are all important, they are not the priority.

Which dietary suggestion should the nurse provide while teaching a group of geriatric female clients who have reduced amounts of circulating estrogen? 1. "Include fish in your diet." 2. "Include fruits in your diet." 3. "Include yogurt in your diet." 4. "Include legumes in your diet."

3. "Include yogurt in your diet." Clients ages 65 years or older are referred to as geriatric. Females usually attain menopause at the age of 55 years. Due to reduced amounts of circulating estrogen in postmenopausal women, bone density decreases, thus increasing the risk of osteoporosis. Geriatric clients should be advised to consume foods rich in calcium such as yogurt, which helps support increases in bone mass. Fish is a good source of omega-3-fatty acids, which maintains a healthy heart. Fruits are rich in fiber, which prevents constipation. Fiber is good for a client's overall health. Legumes are a good source of protein and strengthen the body. However, these dietary suggestions for elderly female clients are less beneficial when compared to the consumption of yogurt.

Which sexually transmitted disease is caused by a virus? 1. Syphilis 2. Gonorrhea 3. Genital warts 4. Chlamydial infection

3. Genital warts Genital warts are caused by a sexually transmitted virus. Bacteria cause syphilis, gonorrhea, and chlamydial infections

A laboring client who is positive for group B Streptococcus (GBS) is given an initial dose of 2 g of ampicillin at 9 AM. According to established guidelines for intrapartum management of this client, what should the next dose be? 1. 2 g given at 10 AM 2. 1 g given at 11 AM 3. 2 g given at noon 4. 1 g given at 1 PM

4. 1 g given at 1 PM The established guidelines for intrapartum antibiotic prophylaxis for a client infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4 hours.

A client undergoes a cesarean birth because of cephalopelvic disproportion. What care is needed for this client in addition to the routine nursing care given to all postpartum clients during the first 24 hours? 1. Encouraging early ambulation 2. Assessing the fundus gently but firmly 3. Checking vital signs for evidence of shock 4. Administering the prescribed pain medication

4. Administering the prescribed pain medication Because of increased pain and increased flatus, clients who have had cesarean births require more pain medication than do women who have vaginal births. Early ambulation is encouraged for all postpartum clients. Although this may be difficult because of the incision, palpating the fundus is a necessary part of postpartum care. Vital signs are checked routinely in all postpartum clients.

A client who has missed two menstrual periods tells a nurse at the prenatal clinic that the home pregnancy test was positive. Her last menstrual period began on June 18. According to Nägele's rule, what is the estimated date of birth (EDB)? 1. March 8 2. March 11 3. March 1 4. March 25

4. March 25 March 25 is the EDB. Using Nägele's rule, take the first day of the last menstrual period (June 18), subtract 3 months, and then add 7 days. March 8, March 11, and March 1 are incorrect calculations according to Nägele's rule.

A client takes isosorbide dinitrate daily. The client states, "I would like to start taking sildenafil for erectile dysfunction." The nurse explains that taking both of these medications concurrently may result in which complication? 1. Constipation 2. Protracted vomiting 3. Respiratory distress 4. Severe hypotension

4. Severe hypotension Concurrent use of sildenafil and a nitrate, which causes vasodilation, may result in severe, potentially fatal hypotension. Protracted vomiting and respiratory distress are not adverse effects associated with concurrent use of sildenafil and a nitrate. Sildenafil may cause diarrhea; adding a nitrate will not constipation.

What instructions should the nurse give to an adolescent to prevent sexually transmitted infections? Select all that apply. 1. "Remember to use condoms properly." 2. "Abstain from any kind of sexual activity." 3. "Make sure you are up-to-date with your vaccinations." 4. "Have sexual contact only if you and your partner are monogamous." 5. "Remember to have regular screenings for sexually transmitted disease."

1. "Remember to use condoms properly." 3. "Make sure you are up-to-date with your vaccinations." 4. "Have sexual contact only if you and your partner are monogamous." The safe use of condoms helps to avoid contact with body fluids and helps prevent sexually transmitted infections. Getting updated with vaccinations helps prevent vaccine-preventable sexually transmitted infections. Monogamous partners have a low risk of contracting sexually transmitted infections. Abstaining from sexual activity is not a practical approach. Regular screening for sexually transmitted infections helps to detect a disease at an early stage, but does not prevent contraction of the disease.

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply. 1. "Wash your hands before touching the newborn." 2. "Send the newborn to nursery to be monitored during the night." 3. "All client identification bands should remain in place until discharge." 4. "Do not let anyone remove the infant from your sight while you are in the hospital." 5. "Check the identification of staff, and if there is a question of validity, call the nursing station."

1. "Wash your hands before touching the newborn." 3. "All client identification bands should remain in place until discharge." 5. "Check the identification of staff, and if there is a question of validity, call the nursing station." Mothers, significant others or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to newborn. Safety is the most important concern. There may be times when procedures, assessments, showering, and other activities involve the newborn being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take the infant out of the mother's sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time.

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include? 1. Assessing respirations, keeping him warm, and identifying him 2. Applying an antibiotic to the eyes, administering vitamin K, and bathing him 3. Aspirating the oropharynx, rushing him to the nursery, and stimulating him often 4. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

1. Assessing respirations, keeping him warm, and identifying him Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor? 1. Cervical dilation 2. Membrane rupture 3. Decreased fetal heart rate 4. Intensification of contractions

1. Cervical dilation True labor is marked by cervical dilation, effacement, or both. It is not uncommon for membranes to rupture before true labor begins. A change in the fetal heart rate does not indicate true labor; the rate may be slowing because the fetus is resting or fetal compromise is occurring. The client's perception of the intensity of contractions is not an indication of true labor. Because of admission to the hospital and loss of diversionary activities, the client may perceive the contractions as becoming more intense.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? 1. Check for a pulse 2. Start cardiac compressions 3. Prepare to defibrillate the client 4. Administer oxygen via an ambu bag

1. Check for a pulse The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

A client asks the nurse about the use of an intrauterine device (IUD) for contraception. Which information should the nurse include in the response? Select all that apply. 1. Expulsion of the device 2. Occasional dyspareunia 3. Delay of return to fertility 4. Risk for perforation of the uterus 5. Increased number of vaginal infections

1. Expulsion of the device 2. Occasional dyspareunia 4. Risk for perforation of the uterus The presence of the IUD thread should be verified before coitus, because the device may be expelled during menses; if the IUD has been expelled, pregnancy can occur. Although dyspareunia is not common, if it does occur, it should be reported. Perforation may occur during insertion of the IUD. The IUD does not affect fertility, as does the oral contraceptive. Immediately after the device is removed the client may try to conceive. The incidence of vaginal infections is not increased with the use of an IUD unless there is unprotected sex with a partner who has a sexually transmitted infection.

Digoxin (Lanoxin) is prescribed for a 1-month-old infant. At the next clinic visit the nurse auscultates the apical pulse at 88 beats/min. What is the nurse's responsibility regarding this pulse rate? 1. Notifying the healthcare provider immediately 2. Telling the mother to continue giving the digoxin 3. Expecting the healthcare provider to lower the dose 4. Asking the mother whether this is the infant's usual heart rate

1. Notifying the healthcare provider immediately Bradycardia (pulse rate slower than 90 to 110 beats/min in infants) is an early sign of toxicity. Additional doses of digoxin will worsen the toxicity. The medication should be stopped; when bradycardia is no longer present, the practitioner may modify the dose. The mother is not a reliable source; the nurse should rely on pulse readings taken before the digoxin was prescribed.

A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. Select all that apply. 1. Oxytocin 2. Misoprostol 3. Ergonovine 4. Carboprost 5. Dinoprostone

1. Oxytocin 2. Misoprostol 5. Dinoprostone Oxytocin is an oxytocic that triggers or augments uterine contractions; it is used for labor induction. Misoprostol is a prostaglandin used for cervical ripening and labor induction. Dinoprostone is used for cervical ripening to induce labor. Ergonovine is an oxytocic used for postpartum or postabortion hemorrhage. Carboprost is a prostaglandin used to treat postpartum hemorrhage.

An epidural anesthetic is planned for the adolescent who is in labor. What nursing interventions are essential before epidural anesthesia is administered? Select all that apply. 1. Performing a baseline vaginal examination 2. Telling the adolescent what to expect with each procedure 3. Identifying risk factors that contraindicate epidural anesthesia 4. Having the parents sign a consent form for the epidural anesthesia 5. Explaining the need to stay in one position while the epidural catheter is in place

1. Performing a baseline vaginal examination 2. Telling the adolescent what to expect with each procedure 3. Identifying risk factors that contraindicate epidural anesthesia A baseline vaginal examination is needed to determine the extent of cervical dilation and effacement. Before any procedure is implemented, the nurse should explain the procedure and answer any questions. Risk factors that contraindicate epidural anesthesia include antepartum hemorrhage, bleeding disorders, and allergy to the medication. None of these conditions is indicated in the client's history. Although a signed informed consent is legally required for this invasive procedure, the adolescent, not the parents, should sign the consent; a pregnant woman is considered an emancipated minor and is legally empowered to sign the consent. The client should change position from side to side every hour to promote distribution of the anesthetic and to maintain circulation to the uterus and placenta.

After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Select all that apply. 1. Profuse scalp hair 2. Parchmentlike skin 3. Abundant vernix caseosa 4. Few rugae over the scrotum 5. Creases covering the entire soles

1. Profuse scalp hair 2. Parchmentlike skin 5. Creases covering the entire soles Profuse scalp hair is associated with a postterm newborn. As the fetus matures, usually the hair on the scalp becomes more profuse. Parchmentlike skin is associated with a postterm newborn. Skin desquamation occurs as a result of prolonged exposure to amniotic fluid, causing cracking, peeling, and drying of skin and resulting in a parchmentlike appearance. Creases will cover the entire sole of each foot if the newborn is full term or postterm; preterm newborns have an absence of or few skin creases on the soles of the feet. Abundant vernix caseosa is associated with a preterm newborn. Postterm newborns exhibit little vernix caseosa. Immature genitals (e.g., undescended testes, small scrotum, few rugae over the scrotum) are associated with a preterm newborn. As the fetus reaches full term and beyond, both testes usually descend, and rugae cover the scrotal sac.

A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can't take this anymore." The husband calls the women's health clinic and asks what he should do. What is the best response by the nurse? 1. Telling him that his wife may be suffering from depression and needs emergency care 2. Telling him that fatigue is expected and that his wife needs to take rest periods during the day 3. Reassuring him that his wife is experiencing postpartum blues that will lessen in several days 4. Advising him to make an appointment for his wife to see her primary healthcare provider if the problem continues

1. Telling him that his wife may be suffering from depression and needs emergency care The mother's inability to care for herself or her children is an ominous sign that postpartum depression is reaching a critical level. The woman needs immediate care to meet her needs and ensure the safety of the children. Between 10% and 15% of new mothers have postpartum depression within 4 weeks of the birth of an infant. Telling the husband that fatigue is expected and that his wife needs to take rest periods during the day ignores the severity of the situation. The client's behavior is indicative of postpartum depression, not postpartum blues. Approximately 80% of women experience postpartum blues ("baby blues"), which peak around the fifth postpartum day and usually subside by the tenth postpartum day. The condition is characterized by a combination of emotional lability, restlessness, depression, let-down feeling, fatigue, insomnia, anxiety, sadness, and anger. Advising the husband to make an appointment for his wife to see her primary healthcare provider if the problem continues ignores the severity of the situation.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. 1. The RR intervals are relatively consistent. 2. One P wave precedes each QRS complex. 3. The ST segment is higher than the PR interval. 4. Four to eight complexes occur in a 6-second strip. 5. The QRS complex ranges from 0.12 to 0.2 seconds.

1. The RR intervals are relatively consistent. 2. One P wave precedes each QRS complex. The consistency of the RR intervals indicates a regular rhythm. A normal P wave before each complex indicates the impulse originated in the sinoatrial (SA) node. Elevation of the ST segment is a sign of cardiac ischemia and unrelated to the rhythm. The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100 beats/min. Fewer than six complexes per 6 seconds equals a heart rate less than 60 beats/min. The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 second.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. 1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's abdomen. 4. The nurse measures the newborn's temperature regularly. 5. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's abdomen. Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

A nurse finds the following (see image) upon assessment of a client. Which organism is responsible for the condition that is illustrated in the image?A.A. with white scabs on the palms of the hands and the sole of the feet. 1. Treponema pallidum 2. Herpes simplex virus 3. Trichomonas vaginalis 4. Neisseria gonorrhoeae

1. Treponema pallidum The client in the image has palmar and plantar secondary syphilis, which is caused by Treponema pallidum. Herpes simplex virus leads to abortions, male urethritis, genital ulcerations, and cervicitis. Trichomonas vaginalis may occur due to vulvovaginitis. Neisseria gonorrhoeae causes gonorrhea, salpingitis, infertility, and ectopic pregnancy.

Which physiologic alteration does the nurse expect in a client's hematologic system during the second trimester of pregnancy? 1. An increase in hematocrit 2. An increase in blood volume 3. A decrease in sedimentation rate 4. A decrease in white blood cells

2. An increase in blood volume The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks' gestation. The hematocrit decreases as a result of hemodilution. The sedimentation rate increases because of a decrease in plasma proteins. White blood cells count remains stable during the antepartum period.

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? 1. Defibrillate 2. Assess the client's pulse 3. Initiate advanced cardiac life support 4. Check another lead to confirm asystole

2. Assess the client's pulse Pulse should be immediately assessed because a lead or electrode coming off may mimic this dysrhythmia. Asystole is characterized by complete cessation of electrical activity. A flat baseline is seen, without any evidence of P, QRS, or T waveforms. A pulse is absent, and there is no cardiac output; cardiac arrest has occurred. Once confirmed, Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) protocols are initiated for asystole. Defibrillation is part of the ACLS protocol for ventricular fibrillation.

What is the desired outcome for the intrapartum client during the third stage of labor? 1. Absence of discomfort 2. Firmly contracted uterine fundus 3. Efficient fetal heart beat-to-beat variability 4. Maternal respiratory rate within the expected range

2. Firmly contracted uterine fundus The third stage of labor spans the time from the birth of the baby to the delivery of the placenta; a firmly contracted uterus is desired because it minimizes blood loss. Providing comfort is a desirable goal, but is secondary to the life-threatening possibility of hemorrhage associated with a boggy uterus. Efficient fetal heart beat-to-beat variability is a concern in the first and second stages of labor; it is no longer applicable after the fetus is born. The maternal respiratory rate may vary above or below this range.

Which assessment finding in a pregnant client should prompt the nurse to notify the primary healthcare provider? 1. Slight dependent edema at 38 weeks' gestation 2. Fundal height at the umbilicus at 16 weeks' gestation 3. Fetal heart rate of 150 beats/min at 24 weeks' gestation 4. Maternal heart rate of 92 beats/min at 28 weeks' gestation

2. Fundal height at the umbilicus at 16 weeks' gestation Fundal height should be at the umbilicus at 20 weeks' gestation. This early fundal height increase indicates a hydatidiform mole, a multiple gestation, or a fetal congenital anomaly; at 16 weeks' gestation the fundus is below the umbilicus in a healthy, single pregnancy. Foot and ankle edema is common as pregnancy reaches term; the enlarged uterus presses on the femoral veins, impeding the flow of venous blood from the extremities. A fetal heart rate of 150 beats/min at 24 weeks' gestation and a maternal heart rate of 92 beats/min at 28 weeks' gestation are within the expected ranges during pregnancy.

The nurse is caring for a client who is on a cardiac rhythm monitor. The nurse notes that the client's P waves are of normal configuration and that each P wave is followed by a QRS complex. All intervals are normal as well, but the client's heart rate is 112 beats per min. How will the nurse interpret this rhythm? 1. Sinus arrhythmia 2. Sinus tachycardia 3. Junctional tachycardia 4. Ventricular tachycardia

2. Sinus tachycardia With sinus tachycardia both atrial and ventricular rates are greater than 100 beats per minute, up to 160 beats per minute, but may be as high as 180 beats per minute. Onset is gradual rather than abrupt. Sinus tachycardia is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is less than 0.12 seconds. QT may shorten. P and QRS waves are consistent in shape. P waves are small and rounded. A P wave precedes every QRS complex, which is then followed by a T wave. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone. In junctional tachycardia, P waves may precede the QRS, and may be inverted or upside down, or the P wave may not be visible or may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened less than 0.12 seconds. The rate for junctional tachycardia is greater than 100 beats per minute. The wave of depolarization associated with ventricular tachycardia rarely reaches the atria. Therefore P waves usually are absent. If P waves are present, they have no association with the QRS complex. The QRS is wide and distorted in shape, lasting more than 0.12 second.

The nurse is helping a mother breast-feed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast? 1. The tongue is securely on top of the nipple. 2. The mouth covers most of the areolar surface. 3. Loud sucking sounds are heard during the 15 minutes spent at each breast. 4. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.

2. The mouth covers most of the areolar surface. Effective attachment involves covering most of the areolar surface of the breast with the newborn's mouth; effective attachment helps compress the milk glands. The nipple must be on top of the newborn's tongue. Loud sucking sounds indicate inadequate attachment. The newborn should suckle for a longer period than 5 minutes; the newborn may be sucking only on the nipple.

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? 1. Deltoid muscle 2. Rectus femoris 3. Vastus lateralis 4. Gluteus maximus

3. Vastus lateralis The vastus lateralis is the most appropriate muscle for a newborn's intramuscular injection because it is well developed and there is little danger of nerve injury. The deltoid muscle is too small for a newborn's intramuscular injection. The rectus femoris muscle is not used; it is not as large as the vastus lateralis in a newborn. The sciatic nerve in the newborn is near the outer aspect of the gluteus maximus and might be injured if this site were used for an injection.

A nurse is caring for a pregnant woman in active labor who is lying in bed in the high Fowler position. Epidural anesthesia and an oxytocin infusion were started 45 minutes ago. The client complains of feeling lightheaded and nauseated. What should the nurse do first after reviewing the client's admission data, vital signs, and current status? 1. Interrupt the oxytocin infusion for 5 minutes. 2. Give the client oxygen via a facemask at 15 L/min. 3. Place the client in a 15-degree side-lying position. 4. Notify the primary healthcare provider that the fetus is experiencing distress.

3. Place the client in a 15-degree side-lying position. The client's blood pressure has decreased, causing supine hypotension. The side-lying position promotes placental perfusion. The contractions and fetal heart rates are within the expected range. Interrupting the oxytocin infusion is counterproductive and will prolong labor. If the client continues to feel lightheaded after the position change, oxygen administration is the next nursing action. The fetal heart rates are within the expected range. Episodic accelerations occur during fetal movement and are indications of fetal well-being. Early decelerations occur in response to fetal head compression and are a benign finding.

While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse's most appropriate action at his time? 1. Call the practitioner to prepare for an imminent birth. 2. Turn the mother on her left side to increase venous return. 3. Record the fetal response to contractions and continue to monitor the heart rate. 4. Document the fetal heart rate abnormality and monitor the fetal heart rate continuously.

3. Record the fetal response to contractions and continue to monitor the heart rate. Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. This increase in the fetal heart rate does not require intervention by the practitioner at this time. Turning the mother on her left side to increase venous return is done when a fetal heart rate deceleration occurs. This is not a fetal heart rate abnormality and does not require a specific amount of time for observation; if the interventions are effective, monitoring should continue as before.

Which intervention would reduce the risk of perinatal transmission via vaginal birth in an adolescent who is diagnosed with HIV infection? 1. Using forceps during delivery 2. Using a fetal scalp electrode during delivery 3. Using antiretroviral during the intrapartum period 4. Administering zidovudine an hour before labor

3. Using antiretroviral during the intrapartum period In the intrapartum period, antiretroviral therapy is recommended to prevent transmission of HIV. Therefore the risk of perinatal transmission may be reduced in an adolescent who receives antiretroviral therapy in the intrapartum period. Use of forceps or fetal scalp electrode during delivery may result in inoculation of the virus into the fetus; therefore, this should be avoided. Intravenous zidovudine should be given during labor, not an hour before it, if the adolescent is having a vaginal birth.

A woman in labor with her third child is dilated to 7 cm, and the fetal head is at station +1. The client's membranes rupture. What is the nurse's priority intervention? 1. Notify the practitioner. 2. Observe the vaginal opening for a prolapsed cord. 3. Reposition the client on a sterile towel on her left side. 4. Check the fetal heart rate while observing the color of the amniotic fluid.

4. Check the fetal heart rate while observing the color of the amniotic fluid. Fetal well-being is the priority. The fetal heart rate will reflect the fetus's response to the rupture of the membranes, and the color of the amniotic fluid will reveal whether there is meconium staining. Notifying the practitioner is necessary if the nurse's assessments reveal fetal compromise. Although checking the vaginal opening for cord prolapse is important, it is not the priority; the fetal head is engaged at station +1. Although positioning the client on the left side promotes placental perfusion, it is not the priority, and a sterile pad is not needed.

A 47-year-old client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse that she has been experiencing hot flashes and that her periods have been occurring at longer, less regular intervals, with a scanty flow. What does the nurse conclude is the most likely cause of these changes? 1. Uterine cancer 2. Lack of estrogen 3. Early cervical carcinoma 4. Expected menopausal changes

4. Expected menopausal changes The adaptations described, along with the client's age, suggest that the client is experiencing menopause. Irregular spotting and bleeding occur with uterine cancer and are not associated with the menstrual cycle. Estrogen is reduced, not eliminated, during and after menopause; the adrenal glands produce a small amount of estrogen throughout life. Early cervical cancer is asymptomatic; an irregular bloody vaginal discharge is a late sign of cervical cancer.

A fetal monitor is applied to a client in labor. The nurse should take immediate action in response to which fetal heart rate? 1. Remains at 140 beats/min during contractions 2. Uniformly drops to 120 beats/min with each contraction 3. Fluctuates from 130 to 140 beats/min unrelated to contractions 4. Repeatedly drops abruptly to 90 beats/min unrelated to contractions

4. Repeatedly drops abruptly to 90 beats/min unrelated to contractions This fetal heart rate change is known as variable-type decelerations. This is indicative of umbilical cord compression that, if left uncorrected, may lead to fetal compromise; interventions are directed at improving umbilical circulation. A fetal heart rate that remains at 140 beats/min during contractions is not an unusual finding and therefore does not require nursing intervention. Uniform drops to 120 beats/min are recurrent early decelerations, a result of fetal head compression during a contraction. They are a benign reflex response requiring no immediate intervention. Fluctuation from 130 to 140 beats/min unrelated to contractions is an expected variation of the fetal heart rate reflecting a well-oxygenated fetal nervous system.

A nurse is planning care with a client for the recovery period after a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What should be included in the information regarding the changes that the client should expect after surgery? 1. Depression 2. Weight gain 3. Urine retention 4. Surgical menopause

4. Surgical menopause When bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones and initiating menopause. Although depression may occur, it is not expected; if it does occur, intervention is required. There is no physiologic reason for weight gain after hysterectomy. Urine retention is not an expected concern, because a urine retention catheter is inserted before surgery and left in place generally for 24 hours, regardless of the type of hysterectomy (e.g., laparoscopic, abdominal, vaginal).

A nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. What other parameter can the nurse use to estimate blood loss in a postpartum client? 1. Odor of the lochia 2. Color of the lochia 3. Presence of small clots on the pad 4. Time elapsed between pad changes

4. Time elapsed between pad changes Hemorrhage may occur after the third stage of labor or during the first 24 postpartum hours; hemorrhage is defined as a blood loss in excess of 500 mL. The best estimation of blood loss takes into consideration a combination of factors, including degree of saturation of perineal pads and frequency of pad changes. The nurse must also assess whether there is pooling of blood under the buttocks. Odor will reflect the possible complication of infection, not hemorrhage. The color of vaginal discharge at this time will not indicate hemorrhage. The color of the lochia during the first postpartum day is expected to be red (rubra). The presence of clots is common and is not an indicator of the amount of blood loss.

A client's membranes rupture during labor, and the amniotic fluid is meconium stained. Which heart rate pattern indicates that the fetus's status is nonreassuring? 1. Early decelerations with average variability 2. Changes in baseline variability from 5 to 10 beats/min 3. Increases in fetal heart rate from 135 to 150 beats/min with fetal activity 4. Variable decelerations that last 60 seconds, then return to baseline tachycardia

4. Variable decelerations that last 60 seconds, then return to baseline tachycardia Variable decelerations indicate cord compression; they should return to baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection, or some other factor that is stressing the fetus. Early decelerations and changes in baseline variability are both expected, benign findings. Increases in fetal heart rate with fetal movement are an expected finding.