NUR 343 Adaptive Quiz #1 Women's Health/Disorders
A client who has syphilis tells the nurse that it must have been contracted from a toilet seat. The nurse knows that this cannot be true because of what property of the causative agent of syphilis? 1 It is immobilized by body contact. 2 It is chelated by wood and plastic. 3 It is inactivated when exposed to a dry environment. 4 It is destroyed when exposed to a warm environment.
3 A dry environment inactivates the Treponema pallidum, making it incapable of causing disease. The organism is transferred by sexual contact; warm, moist body contact supports growth of the organism. Nothing chelates this organism.
The nurse discusses fetal weight gain with a pregnant client. When does the fetus generally show a marked increase in size? 1 During the third trimester 2 During the second trimester 3 At the end of the first trimester 4 No difference is observed.
1 During the third trimester the fetus is laying down fat deposits and gaining the most weight. Fetal weight gain occurs throughout pregnancy, including the second trimester, but it is most marked in the third trimester. There is little fetal weight gain during the first trimester, when organ development is occurring.
The nurse is providing nutrition teaching to a 22-year-old primipara who is 6 weeks pregnant. To decrease the occurrence of neural tube defects in newborns, the nurse would encourage the adequate intake of what nutrient? 1 Niacin 2 Folic acid 3 Vitamin A 4 Vitamin B12
2 Women who take 0.4 mg/day of folic acid during the 4 weeks before pregnancy and during the first trimester reduce the risk of having an infant with a neural tube defect. Vitamins A and B12 and niacin should be included in a balanced diet but do not have the effect on neural tube development that folic acid has.
A nurse is caring for a client during the early postoperative period after a modified radical mastectomy. What should the nurse teach her regarding limiting edema in the affected arm? 1 "Turn to the unaffected side every 2 hours." 2 "Avoid moving the affected arm for 24 hours." 3 "Use pillows to elevate the affected arm above the level of the heart." 4 "Maintain the positive pressure drainage bag below the level of the arm."
3 Elevating the arm allows gravity to facilitate venous return and lymph drainage from the arm. Although basic postoperative recovery involves frequent turning, it has no effect on drainage from the affected arm. Movement of the affected arm is encouraged. Wound drainage involves negative, not positive, pressure.
A client is visiting the prenatal clinic for the first time. While giving the nursing history the client states that her last menstrual period started on June 10. What is her expected date of birth (EDB), according to Nägele's rule? 1 March 3 2 March 10 3 March 17 4 March 24
3 The date is March 17 of the following year. Using Nägele's rule, subtract 3 months from the first day of the last menstrual period and add 7 days. March 3 and March 10 are too early. March 24 is too late.
During the discharge conference with a client who has had a hysterectomy the nurse includes instructions for avoiding the thromboembolic phenomena that may occur as a complication. What should these instructions include? 1 Avoid sitting for long periods of time. 2 Limit fluids to less than 2000 mL per day. 3 Have a blood coagulation test every 2 weeks. 4 Continue with hormone replacement therapy.
1 Sitting for long periods leads to pooling of blood in the pelvic area, predisposing the client to thrombus formation. Fluids should be increased to 3000 mL daily to decrease blood viscosity, which can lead to thrombus formation. Blood coagulation tests are not done routinely, because clotting elements are not usually disturbed by a hysterectomy. Hormone replacement therapy is not considered unless the client is premenopausal and an oophorectomy has been performed.
The partner of a woman experiencing back pain in labor asks what he can do to help. The nurse demonstrates how to apply counterpressure to his partner's back. Where on the image should counterpressure be applied?
Counterpressure on the lower sacrum relieves discomfort by lifting the fetal head off the spinal nerves when the fetus is in a posterior position.
A client at 16 weeks' gestation is scheduled for a sonogram followed by amniocentesis. The nurse instructs the client to drink 8 oz (237 mL) of fluid and not void before the sonogram. What should the nurse explain as the purpose of this? 1 To improve visualization of the fetus 2 To hydrate the mother and increase circulation 3 To hydrate the fetus and decrease fetal movement 4 To replace fluid lost during the procedure
1 A full bladder places the uterus in the optimal position for imaging because it raises the uterus out of the pelvis. Increased circulation is not required before a sonogram and amniocentesis. The purpose of increasing maternal fluid intake before the sonogram is not to hydrate the fetus or decrease fetal movement. After amniocentesis, hydration is encouraged to decrease uterine activity caused by the amniocentesis and support fluid volume.
During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond? 1 "You may use oral contraceptives—they're almost completely effective in preventing pregnancy." 2 "You should use foam with a condom to prevent pregnancy—this is the safest method for women with your illnesses." 3 "You'll find that the intrauterine device is best for you, because it prevents a fertilized ovum from implanting in the uterus." 4 "You have little to worry about regarding becoming pregnant in the near future, because women with your illnesses usually become infertile."
2 Some type of barrier contraceptive (condom with foam or jelly or a diaphragm) is usually recommended for the client with diabetes and heart disease. Oral contraceptives are not recommended for this client because of their tendency to alter glucose tolerance. An intrauterine device is not recommended, because it may predispose this client to infection. Clients with heart disease and diabetes can become pregnant again in the future.
A client's temperature is 100.4° F (38° C) 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature? 1 Mastitis 2 Dehydration 3 Puerperal infection 4 Urinary tract infection
2 A client's temperature may be elevated to 100.4° F (38° C) during the first 24 hours after delivery because of dehydration resulting from the exertion and stress of labor. Mastitis usually develops after breastfeeding is established and the milk supply is present. Puerperal infection usually begins with a fever of 100.4° F (38 °C) or higher on 2 successive days, excluding the first 24 hours after delivery. Urinary tract infection usually becomes evident later in the postpartum period.
A client asks a nurse for contraceptive information regarding a number of different methods available. What information should the nurse include as part of the teaching plan? 1 Sperm cannot reach the ovum if the male uses coitus interruptus. 2 The rim of a condom must be held in place while the penis is withdrawn from the vagina. 3 Diaphragms are equally effective even if the partners choose not to use spermicidal creams. 4 Individuals who use periodic abstinence should have intercourse on days when the woman has an increase in temperature.
2 Unless the condom is held firmly, it can be displaced, allowing the sperm to enter the vagina. Sperm may be deposited at the beginning of intercourse, without the man's knowledge. Spermicidal cream is needed because the diaphragm may be displaced in some positions. When the woman has an increase rise in her basal temperature, she is most fertile and should avoid intercourse.
A client in labor is having an indwelling urinary catheter inserted. What should the nurse plan to do to prevent late decelerations of the fetal heart rate during this procedure? 1 Position both the client's legs simultaneously. 2 Urge the client to take deep breaths frequently. 3 Place a rolled towel under the client's right hip. 4 Loosen the transducer belts around the client's abdomen.
3 Elevating the right hip during catheter insertion displaces the uterus to the left. This action improves placental perfusion and prevents supine hypotension caused by pressure on the vena cava with its associated late fetal heart rate decelerations. Placing the feet in stirrups simultaneously helps prevent trauma to ligaments at the time of birth; it is not done when a urinary catheter is inserted. Breathing frequently is contraindicated because hyperventilation may result. Adjusting the belts around the client's abdomen does not affect the fetal heart rate.
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 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 23-year-old woman comes to the clinic for a Pap smear. After the examination, the client confides that her mother died of endometrial cancer 1 year ago and says that she is afraid that she will die of the same cancer. Which risk factor stated by the client after an education session on risk factors indicates that further teaching is needed? 1 Obesity 2 High-fat diet 3 Hypertension 4 Late-onset menarche
4 Early-onset, not late-onset, menarche is a risk factor for endometrial cancer. A high-fat diet, hypertension, and obesity are all risk factors for endometrial cancer.
During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal infection because of the presence of a white curdlike vaginal discharge. What other finding supports a fungal vaginal infection? 1 A foul odor 2 An itchy perineum 3 An ischemic cervix 4 A forgotten tampon
2 An itchy perineum usually occurs with candidiasis, a fungal infection; pruritus is the most common symptom. An odorous, frothy greenish discharge occurs with trichomoniasis, a protozoal infestation. Ischemia of the cervix is not associated with candidiasis; candidiasis causes vaginal and cervical inflammation. A forgotten tampon may cause bacterial, not fungal, vaginitis.
A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting human immunodeficiency virus (HIV). Which guidance is most appropriate for the nurse to provide? 1 Ask her partner to withdraw before ejaculating. 2 Make certain their relationship is monogamous. 3 Insist that her partner use a condom when having sex. 4 Seek counseling about various contraceptive methods.
3 A condom covers the penis and contains the semen when it is ejaculated; semen contains a high percentage of HIV in infected individuals. Preejaculatory fluid carries HIV in an infected individual, so withdrawing before ejaculation is not effective. Although a monogamous relationship is less risky than having multiple sexual partners, if one partner is HIV positive, the other person is at risk for acquiring HIV. The client is not asking about various contraceptive methods. Most contraceptives do not provide protection from HIV.
A nurse is interviewing a female client with a tentative diagnosis of cystitis pending laboratory results. The nurse anticipates that the causative agent of the cystitis is Escherichia coli. Why does the nurse anticipate this microorganism? 1 It thrives in the kidneys. 2 It is a virulent bacterium. 3 It inhabits the intestinal tract. 4 It competes with fungi for host sites.
3 E. coli is commonly found in the bowel and, because of anatomic proximity and possibly careless hygiene after bowel movements, may spread to the urethra. E. coli is not found in the kidneys. E. coli is no more virulent than other infective agents, nor does it compete with fungal organisms for host sites.
At a routine monthly visit, while assessing a client who is in her 26th week of gestation, the nurse identifies the presence of striae gravidarum. The nurse describes this condition to the client as what? 1 Brownish blotches on the face 2 Purplish discoloration of the cervix 3 Reddish streaks on the abdomen and breasts 4 A black line running between the umbilicus and mons veneris
3 Reddish streaks on the abdomen and breasts are striae gravidarum; they occur as a result of stretching of the breast and abdominal skin. These are known as "stretch marks." Chloasma refers to the condition where brownish blotches develop on the face. Purplish discoloration of the cervix is Chadwick sign. A black line running between the umbilicus and mons veneris is the linea nigra.
A couple at the prenatal clinic for a first visit tells the nurse that their 2-year-old child has just been found to have cystic fibrosis. They state there is no family history of this disorder. They ask the nurse about the chances of their having another child with cystic fibrosis. Knowing that this disorder has an autosomal-recessive mode of inheritance, how should the nurse respond? 1 "There is a 50% chance that this baby will also be affected." 2 "If this baby is male, there is a 50% chance of his being affected." 3 "If this baby is female, there is no chance of her being affected, but she will be a carrier." 4 "There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier."
4 According to Mendelian law, because both parents are carriers, this baby has a 50% chance of being a carrier, a 25% chance of having the disease, and a 25% chance of being unaffected. Because this is an autosomal-recessive gene and not X-linked, there is no difference in prevalence between male and female genetic distribution. Regardless of sex, the infant will have the same risk of being a carrier or noncarrier or having the expressive trait for cystic fibrosis.
As part of an infertility workup involving both partners, a male client is to have a semen analysis. What should the nurse include as part of his instructions? 1 Obtain the specimen upon awakening. 2 Use a condom to collect the semen specimen. 3 Ejaculate at least 4 hours before collection to ensure a pure specimen. 4 Deliver the specimen to the laboratory within 2 hours of obtaining it.
4 Delivering the specimen within 2 hours is necessary to keep the sperm viable for determining sperm count and viability. The specimen can be collected at any time. Rubber solvents and preservatives may affect the semen specimen. Delivering the specimen to the laboratory more than 2 hours after obtaining it may result in an inadequate specimen.
A client at 16 weeks' gestation arrives at the prenatal clinic for a routine visit. During the examination the nurse notes bruises on the client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm what? 1 Domestic abuse 2 Hydatidiform mole 3 Excessive exercise 4 Thrombocytopenic purpura
1 Domestic abuse is likely to intensify during pregnancy, and attacks are usually directed toward the pregnant woman's abdomen. A hydatidiform mole manifests as an unusually enlarged uterus for gestational age accompanied by hypertension, nausea and vomiting, and vaginal bleeding, not bruises on the face and abdomen. Excessive exercise may cause cardiovascular or pulmonary problems. It will not result in bruising. Thrombocytopenic purpura and other bleeding disorders manifest as bruises and petechiae on many areas of the body's surface, not just the face and abdomen.
A nurse determines that a client who, although ambivalent, is considering an abortion because of financial difficulties is in crisis. How should the nurse intervene to alleviate the crisis? 1 Helping the client express her feelings 2 Identifying how family members interact 3 Suggesting that the client seek spiritual counseling 4 Involving the father in the decision-making process
1 The ability to express one's feelings is often a first step in the recognition and resolution of a crisis. Identifying how family members interact is not a priority need; it may come later in the nurse-client relationship. First, the client must explore her own feelings; it is she who should decide whether she wants to seek spiritual counseling or whether the father should be involved in the decision-making process.
On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? 1 Assess her breastfeeding techniques to identify possible causes. 2 Provide a nipple shield to keep the infant's mouth off the nipples. 3 Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. 4 Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.
1 The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.
An older female client tells the nurse in the clinic that she has a cystocele that was diagnosed a year ago. She has urinary frequency and burning on urination. The client asks, "The primary healthcare provider wanted me to have surgery for the cystocele last year; but, I can manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse respond? 1 "Not really, but it should be done." 2 "Yes, you're risking kidney damage." 3 "Yes, you're risking bowel obstruction." 4 "Not really, but you'll be more comfortable if you have it."
2 A cystocele is a herniation of the bladder through the vaginal wall resulting from weakened pelvic structures. In this condition the herniated bladder does not empty effectively, and urinary stasis, chronic infection, and renal failure may result. The surgery improves bladder function and prevents renal failure; it is necessary at this time. Bowel obstruction is a complication of a rectocele, not a cystocele. Although corrective surgery will reduce perineal pressure, its primary purpose is to improve bladder function and prevent complications.
Which client care activity may a nurse safely delegate to an unlicensed health care worker? 1 Assessing a client's mastectomy incision for signs of inflammation 2 Assisting a client who is recovering from an abdominal hysterectomy to the bathroom 3 Providing information about side effects to a client receiving chemotherapy for breast cancer 4 Evaluating the effectiveness of an antiemetic that was administered to a client to relieve nausea
2 An unlicensed health care worker is taught how to safely ambulate clients; this activity does not require extensive nursing knowledge or expert clinical judgment. Assessment, teaching, and evaluation of client responses to care all require clinical judgment and a license to practice nursing.
A client at 42 weeks' gestation is admitted for a nonstress test. The nurse concludes that this test is being done because of what possible complication related to a prolonged pregnancy? 1 Polyhydramnios 2 Placental insufficiency 3 Postpartum infection 4 Subclinical gestational diabetes
2 Placental function peaks at 37 weeks and declines slowly thereafter; therefore continuation of the pregnancy past term (42 weeks) places the fetus at risk because of placental insufficiency. Oligohydramnios (decreased amniotic fluid volume), not polyhydramnios (increased amniotic fluid volume), may occur in postterm gestations. A prolonged pregnancy does not present a risk for a postpartum infection. A prolonged pregnancy is unrelated to gestational diabetes.
A 28-year-old woman is diagnosed as having cancer of the left breast. A simple mastectomy is performed. What should the plan of care include immediately after surgery? 1 Changing the client's pressure dressing as necessary 2 Inviting a member of Reach to Recovery to visit the client 3 Placing the client in the semi-Fowler position with the left arm elevated 4 Waiting for a cessation of drainage before the client resumes any activity
3 The semi-Fowler position and elevation of the arm on the affected side minimize edema related to the inflammatory process. Pressure dressings are rarely used, because portable wound drainage systems are used to remove accumulated fluid from the surgical site. A member of Reach to Recovery will not visit on the day of surgery; the visit will probably be made in the client's home. Activities of daily living that necessitate only slight flexion of the elbow and do not involve abduction of the arm on the affected side are permitted.
The nurse is planning care for a middle-aged woman who has been admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. What should the nurse tell the client to expect in the immediate postoperative period? 1 Placement of a pessary 2 Insertion of a rectal tube 3 Use of a douche periodically 4 Presence of a urinary catheter
4 After surgery the urethral orifice may be distorted and edematous; a urine retention catheter keeps the bladder empty, limiting pressure on the operative site. A pessary placed in the vagina is used for a displaced uterus; after an anteroposterior repair (colporrhaphy), vaginal packing is used to support the surgical repair. A rectal tube is used for abdominal distention caused by flatulence; it is rarely necessary. A cleansing douche may be prescribed before, not after, surgery.
A client who recently gave birth is transferred to the postpartum unit by the nurse. What must the nurse do first to prevent a charge of client abandonment? 1 Assess the client's condition. 2 Document the client's condition and the transfer. 3 Orient the client to the room and explain unit routines. 4 Report the client's condition to the responsible staff member assuming her care.
4 Because the nurse is responsible for the client's care until another nurse assumes that responsibility, the nurse should report directly to the client's primary nurse. Making an assessment of the client's condition is not enough. Although documentation is important, it is insufficient. Orienting the client to the room and explaining unit routines is insufficient. Although the nurse should carry out these activities, they may be done after the nurse reports the client's condition to the staff.
A pregnant couple is attending childbirth preparation classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor? 1 Pelvic tilt 2 Half sit-ups 3 Pelvic rocking 4 Kegel exercises
4 Kegel exercises increase the tone of pelvic floor muscles and prepare the area for the second stage of labor. Pelvic tilting alleviates backache and strengthens the abdominal muscles, not the muscles of the pelvic floor. Half sit-ups strengthen the abdominal musculature, not the muscles of the pelvic floor. Pelvic rocking alleviates backache and strengthens abdominal muscles, not the muscles of the pelvic floor.
A 49-year-old client is admitted with a diagnosis of cervical cancer. As the nurse is obtaining her health history, she says, "I haven't had a Pap smear for more than 5 years. I probably wouldn't be in the hospital today if I'd had those tests more often." What is the nurse's most appropriate response? 1 "Please tell me why you waited so long." 2 "You feel as though you've neglected your health." 3 "It's never too late to start taking care of yourself." 4 "Most women hate to have Pap smears done, but they're really important."
2 Stating that the client feels that she's neglected her health indicates recognition of expressed feelings; a nondirective and reflective response encourages verbalization. Asking the client why she waited so long ignores the client's current emotional needs; direct statements often do not elicit feelings and may cut off communication. Stating that it is never too late to start taking care of her health is a judgmental response, because it implies that the client has been negligent. Although it is true that most clients hate to have Pap smears, this statement ignores the client's current emotional needs.
A nurse in the postpartum unit must complete several interventions before a client's discharge from the hospital. The nurse plans to delegate some of the tasks to an unlicensed health care worker. Which activity must be performed by the nurse? 1 Taking the neonate's picture 2 Placing the infant car seat in the car 3 Comparing the identification bands of mother and infant 4 Preparing the discharge packet and distributing them to parents
3 It is the nurse's professional responsibility to compare the mother's and infant's identification bands one last time before discharge. This ensures that the correct infant is discharged with the mother. Taking the neonate's picture, placing the infant seat in the car, and preparing the discharge packets and distributing them to parents are all within the role of the nursing assistant and may be delegated safely.
What important intervention should be included in the nursing care provided immediately after a sexual assault? 1 Obtaining the assault history from the client 2 Informing the police before the client is examined 3 Having the client void a clean-catch urine specimen 4 Testing the client's urine for seminal alkaline phosphatase
1 Obtaining the assault history from the client provides a basis for assessing trauma; in a client of childbearing age it also is necessary to assess the risk for pregnancy. Examination may precede reporting; the decision to report is mandated by law. Urination may wash away spermatic or bloody evidence. A test for seminal acid phosphate, not seminal alkaline phosphatase, is performed.
A client with a history of endometriosis has abdominal surgery to remove abdominal adhesions. What should this client's postoperative plan of care include? 1 Encouraging the client to ambulate in the hallway 2 Elevating the client's legs by gatching the bed 3 Helping the client dangle her legs over the side of the bed 4 Maintaining the client on bed rest until the dressings have been removed
1 Muscle contraction during ambulation improves venous return, which prevents venous stasis and thrombus formation. Gatching the bed and dangling the legs each place pressure on the popliteal spaces, limiting venous return and increasing the risk of thrombus formation. Bed rest is associated with venous stasis, which increases the risk of thrombus formation.
A client who is to undergo dilation and curettage and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally? 1 Explaining that these procedures are considered minor surgery 2 Asking whether something is troubling the client and whether she'd like to talk about it 3 Stating that the procedures are routine and asking what the client is really worried about 4 Explaining that everybody is fearful before the surgery even though there is little reason to worry
2 Asking whether the client wants to talk about what's troubling her acknowledges that the client is anxious and, by means of indirect questioning, helps facilitate communication. Saying that these procedures are considered minor surgery denies the client's feelings. The client has not indicated that she is upset, and she may be unaware of or unable to verbalize the actual cause of the emotions. Saying that there is little reason to worry is false reassurance and cuts off communication.
After a mastectomy or a hysterectomy a client may feel incomplete as a woman. Which statement should alert the nurse to this feeling in a client who has undergone a total hysterectomy? 1 "I can't wait to see all my friends again." 2 "I feel washed out; there isn't much left." 3 "I'm planning to recuperate at my daughter's home." 4 "I can't wait to get home; I so want to see my grandchild."
2 The client's statement implies emptiness with an associated loss. Resumption of social activities indicates acceptance by the client of her condition and a willingness to move on with life. Stating that she is to recuperate at her daughter's home indicates that the client is planning for the future, not expressing a sense of loss. Being excited to get home is a response typical of a grandmother anxious to resume her life.
A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, "After I have this surgery I know my husband will never come near me again." What is the nurse's best initial response? 1 "You're underestimating his love for you." 2 "You're wondering about the effect on your sexual relations." 3 "You're worried that the surgery will change how others see you." 4 "You're concerned about how your husband will respond to your surgery."
4 Stating that the client is concerned about how her husband will respond to her surgery is an open-ended response that encourages further discussion without focusing on an area that the nurse, not the client, feels is the problem. Accusing the client of underestimating her husband's love denies the client's feeling and may cause feelings of guilt for questioning the partner's love. Wondering about the effect on sexual relations is too specific; the nurse does not have enough information to come to this conclusion. Worrying that the surgery will change how others see the client shifts the focus from the client's voiced concerns; the client specifically referred to her husband, not others.
A pregnant client in the first trimester is experiencing nausea and vomiting. What does the nurse determine about this discomfort? 1 It is always present during early pregnancy. 2 It will disappear when lightening occurs. 3 It is a common response to an unwanted pregnancy. 4 It may be related to an increased human chorionic gonadotropin level.
4 An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown. Some pregnant women do not experience nausea and vomiting. Lightening occurs at the end of the third trimester; nausea and vomiting usually cease at the end of the first trimester. Nausea and vomiting are unrelated to whether a pregnancy is desired or unwanted.
A 30-year-old woman is scheduled for a total abdominal hysterectomy because of noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. What is the most common reason for this difficulty? 1 Loss of femininity 2 Body image changes 3 Diminished sexual desire 4 Slow postmenopausal recovery
1 Removal of the uterus may produce changes in how some women view themselves sexually because it is a reproductive organ. Although body image changes are possible, they are more likely to occur with surgery that involves obvious external changes. The libido of a postmenopausal woman will probably not be altered unless she has concerns about sexuality. A 30-year-old otherwise healthy woman should have an uneventful recovery.
A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. Which aspect of the client's life is most important for the nurse to explore at this time? 1 Sexual history 2 Support system 3 Obstetric history 4 Elimination patterns
2 During a health crisis the client will need support from significant others. The sexual history is important in diagnosis and the obstetric history and elimination patterns are important parts of the medical history; however, none are the priority at this time.
A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean birth. What should the nurse tell the client to expect? 1 "We'll give you an enema before the surgery." 2 "We'll be encouraging you to walk early after surgery." 3 "You'll be discharged from the hospital in a week." 4 "You should take sponge baths until the incision is healed."
2 Early postoperative ambulation helps prevent such postpartum complications as thrombophlebitis and constipation. An enema is not necessary. Clients who have had uncomplicated cesarean births are generally discharged by the third postpartum day. Clients are permitted to shower after 48 hours or even sooner.
A client visits the prenatal clinic because her menstrual period is late. Her last period was April 5. Testing confirms that she is pregnant. According to Nägele's rule, what date should the nurse provide as the expected date of birth (EDB)? 1 January 5 2 January 12 3 January 19 4 January 26
2 January 12 is the EDB. Using Nägele's rule, subtract 3 months and add 7 days from the client's last menstrual period. January 5, January 19, and January 26 all represent inaccurate applications of Nägele's rule.
During labor a client tells the nurse that she and her husband are very concerned because the baby will be born 2 months early. How should the nurse respond? 1 "You should be concerned. I feel for you." 2 "If you're concerned, let's talk about it." 3 "Try not to worry about it; just concentrate on your labor." 4 "Don't worry; the care of preterm babies has greatly improved."
2 Offering to talk with the client encourages her to verbalize concerns, which serves as an outlet for tension. Telling the client that she should be concerned reinforces her fears, and it conveys sympathy, not empathy. Telling the client not to worry about it denies the client's feelings and cuts off communication. Telling the client not to worry because the care of preterm babies has improved denies the client's feelings and represents false reassurance.
A woman is being prepared for a contraction stress test (CST). Which information should the nurse provide the client before the test? 1 "The test will be discontinued after at least six contractions are observed." 2 "You'll need to provide a double-voided urine specimen before the test." 3 "The fetal heart rate will be monitored for about 20 minutes before the test begins." 4 "You'll be placed in a right lateral position that must be maintained throughout the test."
3 The fetal heart rate (FHR) is measured for about 20 minutes before the CST to determine baseline variability and to detect any FHR alterations without induced stress. The test involves monitoring the fetal heart rate during three to five uterine contractions over a 10-minute period. A urine sample is unnecessary. The semi-Fowler position with a left-sided tilt is the position of choice.
A 28-year-old woman who has phenylketonuria (PKU) visits the fertility clinic for genetic counseling. After deciding that she wants to become pregnant, she tells the nurse that she ate a low-phenylalanine diet until she was 18 years old. What is the nurse's best response? 1 "Eat a regular pregnancy diet after becoming pregnant." 2 "Start the low-phenylalanine diet during the third trimester." 3 "Maintain a low-protein diet starting in the second trimester." 4 "Return to the low-phenylalanine diet before becoming pregnant."
4 It is essential that a woman with PKU return to a low-phenylalanine diet before becoming pregnant; phenylalanine crosses the placenta, and a high blood level can damage the fetus, especially during organogenesis. Eating a regular pregnancy diet can endanger the fetus. Starting the low-phenylalanine diet in the third trimester is too late to protect the fetus. Advising a client to eat a low-protein diet is too vague, and starting the diet in the second trimester is too late to protect the fetus.
A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What priority action should the nurse instruct the client to take? 1 "Stay in bed for at least 3 days." 2 "Keep the legs elevated while sitting." 3 "Apply a warm compress to the affected calf twice a day." 4 "Call an ambulance to go to the emergency department."
4 The client's description of her problem is indicative of thrombophlebitis; this is a medical emergency because it may precipitate a pulmonary embolism. The client must be assessed by a primary healthcare provider. Intravenous anticoagulants will probably be necessary. Although bed rest may be prescribed eventually, a delay in pharmacologic treatment may jeopardize the client's status. Elevation of the legs may be prescribed eventually, after the thrombophlebitis is resolved. Although warm compresses are commonly prescribed, a delay in pharmacologic treatment may jeopardize the client's status.
The nurse has completed a prenatal class for women who are all expectant with their first child. Which statement by a pregnant woman indicates the need for additional teaching? 1 "During pregnancy it's safe for me to use my regular herbal remedies." 2 "My doctor will tell me if it's safe for me to take my allergy medications." 3 "I should avoid all x-rays unless absolutely necessary and tell the technician that I'm pregnant." 4 "I'm only 18 weeks pregnant, so it's safe for me to go through the airport security check when I go on vacation next month."
1 Herbal remedies can be harmful to the fetus. All medications, including allergy medications, should be cleared through the healthcare provider. Radiation from x-rays can be harmful to the fetus. However, the amount of radiation encountered in airport security over the course of a single trip would not pose a risk to the fetus.
While being admitted for a lumpectomy the client begins to cry and says, "I found the lump a few months ago, but I didn't go to the doctor because of what it could be." How should the nurse reply? 1 "This has been frightening for you." 2 "About 80% of breast lumps are benign." 3 "Cry as long as you like and get it out of your system." 4 "More than 95% of breast lumps are discovered by the woman herself."
1 Saying "This has been frightening for you" involves the use of a reflective technique to acknowledge the client's feelings. Providing statistics does not acknowledge the client's feelings and may cut off communication. Providing false reassurance that crying will ease her concerns is inappropriate.
After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that both she and her partner are visibly upset. The partner has tears in his eyes, and the client is sobbing quietly with her face turned to the wall. At this time, what is the nurse's most therapeutic statement? 1 "I'll be here if you want to talk." 2 "Try to relax—it'll speed the healing process." 3 "With any luck you'll get pregnant again soon." 4 "It's best that this happened early rather than having the baby die after it was born."
1 Saying, "I'll be here if you want to talk" gives the client and her partner room to comfort each other while letting them know that the nurse is available; it also gives the couple time and space in which to recognize and accept their feelings of loss. Telling the couple to relax denies their feelings and may cut off communication. Telling the client that she will become pregnant again soon minimizes the couple's grief over this loss and cuts off further communication. Also, an assumption is made that another pregnancy will occur. Telling the client that it is best that the miscarriage happened early rather than having the baby die after it was born is an insensitive statement. Grieving for a loss is not confined to when the loss occurs, either during the pregnancy or after the birth.
What information does the nurse need to teach a client in order for her to perform an accurate breast self-examination? 1 Squeeze the nipples to examine for discharge. 2 Use the right hand to examine the right breast. 3 Place a pillow under the shoulder opposite the examined breast to raise it. 4 Compress breast tissue to the chest wall with the palm to palpate for lumps.
1 Serous or bloody discharge from the nipple is pathologic and must be reported. The right hand should be used to examine the left breast because this allows the flattened fingers to palpate the entire breast, including the tail (upper, outer quadrant toward the axilla) and axillary area. A small pillow or rolled towel should be placed under the scapula of the side being examined because it helps raise the chest wall and spread and flatten out breast tissue. The flat part of the fingers, not the palm or fingertips, should be used for palpation.
After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. What is the nurse's best response to this comment? 1 "This must be very difficult for you with this added pressure." 2 "Having a child is a decision you should make without your parents' input." 3 "You're lucky. It's nice that your parents are making such a generous offer." 4 "Five years without a pregnancy is a long time. You were right to come to the fertility clinic."
1 Stating that the situation must be difficult encourages the clients to verbalize their feelings. The clients are not seeking advice concerning their relationship with their parents; the focus should be on them. Stating that five years without a pregnancy is a long time is an insensitive statement and cuts off further communication.
A nurse explains to a nursing class that the efficiency of the basal body temperature method of contraception depends on fluctuation of the basal body temperature. Which factor can alter the effectiveness of this method? 1 Stress 2 Length of abstinence 3 Age of those involved 4 Frequency of intercourse
1 Stress or infection can alter the body's metabolism, causing an elevation in temperature; a rise in temperature from these causes may be misinterpreted as ovulation. Length of abstinence may increase sperm volume, but does not affect the female's basal temperature. Age is not a factor in the efficiency of the basal body temperature method of contraception in premenopausal woman. Frequency of intercourse may affect the volume of sperm, but does not alter the female's basal temperature.
A woman who is pregnant for the first time is concerned about regaining her figure after the baby is born and wishes to diet during pregnancy. How should the nurse advise her? 1 Inadequate food intake can result in a low-birth-weight infant. 2 Dieting is recommended to decrease the risk of stillbirth. 3 Dieting is recommended to make the birthing process easier. 4 Inadequate food intake may result in gestational diabetes mellitus.
1 The recommended weight gain is at least 25 lb (11.3 kg) for this client; inadequate intake of nutrients during pregnancy results in an underweight newborn. The cause of stillbirth is usually not known; however, dieting during pregnancy is not recommended, because it can result in congenital anomalies, as well as low birth weight. Inadequate food intake is not a risk factor for gestational diabetes mellitus.
Which action involving client needs may a nurse delegate to an unlicensed health care worker? 1 Assessing a newly admitted client's contraction pattern 2 Discussing pain management options with a laboring client 3 Providing ice chips to a primigravida in early labor per the primary healthcare provider's prescription 4 Obtaining a sterile urine specimen for a suspected urinary tract infection
3 Providing ice chips to a primigravida in early labor per the primary healthcare provider's prescription does not require clinical knowledge or judgment for safe, effective care. Assessment, discussion of alternative actions, and the use of sterile technique during an invasive procedure all require clinical knowledge and judgment beyond the scope of practice of an unlicensed health care provider.
A pregnant client tells the nurse that her husband is a chain smoker. What information should the nurse's teaching include? 1 Secondhand smoke is related to an increased blood level of alpha-fetoprotein. 2 Continued exposure to secondhand smoke is related to fetal growth restriction. 3 If the mother does not smoke, the fetus will not be affected by secondhand smoke. 4 If the mother is not in the same room where there is smoking, the fetus is not affected.
2 Exposure to secondhand smoke decreases the oxygen-carrying capacity of Po2, thereby depriving the fetus of nutrients and oxygen, which results in intrauterine growth restriction (IUGR). An increased blood level of alpha-fetoprotein, not exposure to secondhand smoke, is associated with neural tube defects. Both mother and fetus are affected by secondhand smoke. The fetus is affected by secondhand smoke because the environment is contaminated with the end products of burning tobacco.
A client who recently was told by her primary healthcare provider that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. The nurse determines that the client is experiencing which stage of death and dying? 1 Anger 2 Denial 3 Bargaining 4 Acceptance
2 The client has difficulty accepting the inevitability of death and is attempting to deny the reality of it. In the anger stage the client strikes out with "Why me?" and "How could God do this?" type of statements. The client is angry at life and still angrier to be removed from it by death. In the bargaining stage the client tries to bargain for more time. The reality of death is no longer denied, but the client attempts to manipulate and extend the remaining time. In the acceptance stage the client accepts the inevitability of death and peacefully awaits it.
A 37-year-old client with a nontender palpable breast mass has an inconclusive mammogram. She is undergoing further diagnostic tests to determine whether the mass is malignant. What information should the nurse take into consideration before planning health teaching for this client? 1 Squamous cell carcinomas are neoplasms arising from glandular tissues. 2 Results of a biopsy are necessary before a specific form of therapy is selected. 3 Mammographies should be repeated to confirm the presence of malignancies. 4 Waiting for several weeks before receiving confirmation of cancer is helpful to the client.
2 The therapy selected depends on whether there is a malignancy and, if so, the type of cancer cells, the extent of nodal involvement, and the presence and extent of metastasis. Adenocarcinomas, not squamous cell carcinomas, arise from glandular tissue; squamous cell carcinomas arise from epithelial tissue. Only a biopsy will confirm the diagnosis of a malignancy. Waiting several weeks for a diagnosis is not advisable; an extended waiting period increases the client's stress and anxiety.
A client visiting the prenatal clinic for the first time tells the nurse that she has heard conflicting stories regarding sex during pregnancy and asks about continuing sexual activity. How should the nurse respond? 1 "You should discontinue intercourse after the second trimester." 2 "This information can be given only by your obstetrician or nurse-midwife." 3 "With an uncomplicated pregnancy, there are no limitations on sexual activity." 4 "Sexual activity should be avoided during the first and last six weeks of pregnancy."
3 Although there are no limitations on sexual activity, as the pregnancy progresses the client and her partner may need some guidance in altering positions to make sexual activity more comfortable. Intercourse may be continued throughout the entire pregnancy if there are no complications. Information on sex may be given by a professional nurse; it is not necessary to refer this client to another care provider. Avoiding sexual activity during the first and last six weeks of pregnancy is unnecessary if the cervical plug is still in place and the membranes are intact.
A 16-year-old high school student is referred to a community health center by a local hotline because of the fear of having contracted herpes. The teenager is upset and shares this information with the community health center nurse. What should the nurse's initial response be? 1 "Let me get a brief health history now." 2 "Try not to worry until you know whether you have herpes." 3 "You sound worried. Let me make arrangements to have you examined." 4 "Herpes has received too much attention in the media; let's be realistic."
3 Telling the client that she sounds worried and offering to arrange an examination immediately identifies the client's fear as real and offers a service to meet the need for information about the client's physical status. Obtaining the health history ignores the client's concern and focuses on the nurse's need to complete the task of obtaining a history. Telling the client not to worry minimizes the client's concern about having a sexually transmitted infection. Saying that herpes has received too much attention in the media minimizes the client's concern and implies that the client is being unrealistic.
A client with osteoporosis has been receiving dietary information from the nurse. Which food selection by the client indicates that the nurse's dietary instruction was effective? 1 Red meat 2 Soft drinks 3 Turnip greens 4 Enriched grains
3 Turnip greens are high in calcium and vitamins. A high level of nitrogen from protein breakdown may increase the release of calcium from bone to serve as a buffer of the nitrogen. Soft drinks that are high in phosphorus may interfere with calcium absorption from the gastrointestinal (GI) tract. Enriched grains that are high in phosphorus may interfere with calcium absorption from the GI tract.
A pregnant client tells the nurse, "I'm sticking to my diet, and I don't eat anything containing salt." How should the nurse respond? 1 "You're doing fine. Just keep up the good work." 2 "A low-salt diet will protect you from getting swollen feet." 3 "We now encourage pregnant women to increase their salt intake because of changes in the circulation." 4 "Salt is necessary in your diet. Use a little when you're cooking, but avoid processed meats and canned foods with salt."
4 Blood volume increases during pregnancy; sodium is required to maintain physiologic edema in interstitial spaces so blood volume is not depleted. High-sodium processed meats and canned foods with added salt are discouraged in diets for all adults, not just pregnant women. Telling the client that she is doing fine is false reassurance. It is necessary to have some salt in the diet, and the mother should be taught about its function in pregnancy. Physiologic edema is expected and is helpful in keeping an adequate volume of blood in the intravascular space; a low-salt diet will not prevent dependent edema as the pregnancy nears term. Increasing salt intake during pregnancy is unnecessary. There is enough salt in the average diet to meet the increased sodium needs of pregnant women.
A 26-year-old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center for an appointment for a mammogram. What guidance should the nurse provide the client in preparation for the test? 1 Do not eat for 6 hours before the test. 2 The room will be darkened throughout the procedure. 3 The first mammogram is usually performed at 50 years of age. 4 During the procedure, each breast will be compressed firmly between two plates.
4 Compression of the breast flattens mammary tissue and maximizes penetration of the breast by x-rays; this is especially important for the dense breast tissue of adolescents, young nulliparous women, and women with large breasts. Fasting before the test is not necessary. The room is usually darkened for sonography, not mammography. The American Cancer Society recommends that women at risk for breast cancer (the client's sister had breast cancer) should have routine mammography, regardless of age or relationship to menopause. It is recommended that a woman have her first mammogram by age 40 to establish a baseline for future annual mammograms.
The nurse is obtaining the history of a client in the third trimester who is visiting the prenatal clinic for the first time. She tells the nurse she has two toddlers at home, that their father abandoned the family last month, and that she doesn't know what to do. The nurse concludes what about the client's emotional state? 1 Angry that the father has left 2 Overwhelmed by the situation 3 Ambivalent about her pregnancy 4 Denying the reality of her pregnancy
2 Because of the difficult home situation, this client is experiencing multiple stressors that could cause difficulty with coping. There is no information to support the conclusion that the client is angry or that she is ambivalent about the pregnancy. The client is attending the prenatal clinic, which indicates that she is aware of reality and is not in denial.
A client has been taking methadone 40 mg/day for treatment of an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do? 1 Withdraw the methadone slowly over the next several weeks. 2 Continue the prescribed methadone to prevent withdrawal symptoms. 3 Temporarily discontinue the methadone to improve maternal and neonatal outcome. 4 Leave the methadone maintenance program during the pregnancy and reenter it after the birth.
2 Methadone is the only medication approved for the treatment of pregnant women with opioid addiction. Although methadone crosses the placenta, it is considered safer for the newborn than the acute opioid detoxification that would result if the methadone was not administered. Withdrawing the methadone slowly over the next several weeks is not recommended. Detoxification from methadone, a long-acting opioid, takes longer than several weeks. Discontinuing methadone treatment can lead to withdrawal problems and put the client at risk for a return to opioid abuse. If methadone is discontinued during the pregnancy, both client and fetus will be at risk.
A woman arrives at the prenatal clinic stating that her pregnancy test is positive. She asks the nurse for information regarding an abortion. After verifying that the woman is at 8 weeks' gestation, the nurse counsels her that having an abortion is controversial and that many women have long-lasting feelings of guilt after an abortion. What is the nurse's legal responsibility? 1 To share her own thoughts on abortion with the client 2 To provide the client with correct, unbiased information 3 To ask why the client wants information about abortion 4 To notify the primary healthcare provider because this is beyond the scope of nursing practice
2 Nurses who counsel clients regarding abortion should know what services are available and the various methods that are used to induce abortion. Nurses who cannot control their negative feelings regarding abortion should not counsel women who are thinking of undergoing the procedure. Nursing practice necessitates knowledge of research results; statements must be based on fact, not personal feelings or beliefs. The nurse should give the client only the information requested, not state personal feelings. The nurse is responsible for giving information about abortion and need not defer to the primary healthcare provider.
A client who has had a lumpectomy of the breast is about to undergo radiation therapy. What should the nurse's initial action be when the client visits the surgeon's office for the first postoperative appointment? 1 Provide a protective skin lotion. 2 Assess the extent of wound healing. 3 Teach sterile technique for skin care. 4 Demonstrate how to dispose of urine safely.
2 Radiation will interfere with wound healing if it is initiated too soon; inadequate healing should be reported to the primary healthcare provider. Topical preparations should not be used unless prescribed. Sterile technique is not necessary unless there is a break in the skin. Urine and other excreta of a client receiving radiation to the breast area are not affected by the radiation.
A client gives birth to a healthy girl. Her husband expresses delight but appears anxious and tends to avoid physical contact with his newborn. Later he says to the nurse, "My wife seems so wrapped up in the baby—I hope she has time for me." How should the nurse respond? 1 "Your parents may be able to help you and your spouse." 2 "You feel that you'll have to fend for yourself. Tell me more about your concerns." 3 "Your concern about future adjustments in your life is valid." 4 "You'll both be so busy that you won't even miss her attention."
2 Stating that the father feels that he'll have to fend for himself identifies the husband's concern and invites the husband to further explore his feelings. There is not enough information for the nurse to offer a specific suggestion for help. Stating that the husband's concern about future adjustments in his life is valid is a value judgment. Also, it does not invite exploration of feelings. Stating that they will both be so busy that the father won't even miss his wife's attention may compound the anxiety; also, it does not permit the exploration of feelings.
A female client who has been sexually active for 5 years is diagnosed with gonorrhea. The client is upset and asks the nurse, "What can I do to keep from getting another infection in the future?" Which statement by the client indicates that the teaching by the nurse was effective? 1 "I'll douche after each time I have sex." 2 "Having sex is a thing of the past for me." 3 "My partner has to use a condom all the time." 4 "I'll be using a spermicidal cream from now on."
3 Although not 100% effective, a condom is the best protection against gonorrhea in a sexually active person. Douching has no proven protective effect against sexually transmitted infections; excessive douching can alter the natural environment of the vagina and may even promote an ascending infection. Although abstaining from sex is the best way to prevent a sexually transmitted infection, it is not the most realistic response for a sexually active person. Once people become sexually active, they usually remain sexually active. Spermicidal creams do not have a protective effect against sexually transmitted infections; spermicides kill sperm and limit the risk for pregnancy.
A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant? 1 Go buy maternity clothes. 2 Start running 3 miles (4.8 km) a day. 3 Start taking prenatal vitamins. 4 Buy a crib for the baby to sleep in.
3 Folic acid is important for the pregnant woman; a lack of folic acid can result in neural tube defects, including spina bifida. The time during fetal development when this occurs is very early in the pregnancy, when the woman may not even realize that she is pregnant. Taking prenatal vitamins with adequate folic acid can greatly reduce this birth defect. Although exercise is good for the pregnant woman and infant, it is not necessary to start running 3 miles (4.8 km) a day, especially if this is something the client has never done before. Running may not be healthy for the soon-to-be mother and infant if it is a new activity; however, if this is what the woman normally does, she will be encouraged to continue. Buying maternity clothes or a crib is not necessary at this stage, and neither of these directly affects the health of the baby.
Before an amniocentesis, both parents express anxiety about the fetus's safety during the test. Which nursing intervention is most appropriate in promoting the parents' ability to cope? 1 Initiating a parent-primary healthcare provider conference 2 Reassuring them that the procedure is safe 3 Explaining the procedure, step by step 4 Arranging for the father to be present during the test
3 Giving the parents information about what to expect during the procedure will help allay their fears and encourage their cooperation. The nurse should be able to provide information and interpretation of procedures for clients; a delay in answering questions may increase a client's concerns. Amniocentesis is a low-risk procedure; however, some complications may occur. If the father is uninformed, viewing the procedure may increase his anxiety, even though his presence may be comforting to the mother.
Before discharge, a breastfeeding postpartum client and the nurse discuss methods of birth control. The client asks the nurse, "When will I begin to ovulate again?" How should the nurse respond? 1 "You should discuss this at your first clinic visit." 2 "Ovulation will occur after you stop breastfeeding." 3 "Ovulation may occur before you begin to menstruate." 4 "I really can't tell you, because everyone is so different."
3 If the client is breastfeeding, ovulation and fertility may occur before menstruation resumes. It is the nurse's responsibility to answer the client's questions rather than putting the client off. Ovulation may occur while a woman is breastfeeding because the process of follicular maturation begins when the prolactin level decreases. Declining to answer by claiming that every woman is different evades the question; there are general guidelines that the nurse can share with the client.
When a client who has had a mastectomy returns from surgery, a dressing and a portable wound drainage system to the axillary area are in place. The nurse notes an excessive amount of serosanguineous drainage on the mastectomy dressing. What is the nurse's next action? 1 Notifying the surgeon 2 Applying a pressure dressing Correct3 Checking the function of the drainage system 4 Using additional pillows to elevate the affected arm
3 If the tubing is patent and negative pressure is present, the wound should be free of exudate. Drainage is expected; it is the nurse's responsibility to maintain the drainage system. Pressure dressings are not used with portable wound drainage systems because the systems are effective in removing interstitial fluid. Although elevating the arm may facilitate drainage, it is not the priority in relation to the data presented.
After treatment for a bladder infection, a client asks whether there is anything she can do to prevent cystitis in the future. What is the best response by the nurse? 1 "Avoid regular use of tampons." 2 "Decrease your intake of prune juice." 3 "Increase your daily fluid consumption." 4 "Cleanse the perineum from back to front."
3 Increasing fluid intake flushes the urinary tract of microorganisms. Tampons do not increase the risk of cystitis. Fluids should be increased, not decreased; prune juice promotes acidic urine, which is desirable because it discourages the growth of microorganisms. The preferred method of cleansing is from front to back (urethra to vagina); however, studies have shown that this method of cleansing is not a significant factor in the prevention of cystitis.
A nurse assesses a 35-year-old multiparous client who is scheduled for a tubal ligation to determine her emotional response to the planned procedure. What factor in the client's history will contribute most to the healthy resolution of any emotional problem associated with sterilization? 1 Belief that surgery will relieve her monthly dysmenorrhea 2 Knowledge that her partner does not want to have any more children Correct3 Feeling that her family is complete and she now has the children that were planned 4 Recovery from her previous complicated birth and does not want to experience another birth
3 Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should have no effect on dysmenorrhea. The decision for sterilization should not be made by others, only by the woman herself. Decisions regarding sterilization should not be made when the client is under stress.
After an uneventful 8-hour labor a client gives birth. Once the airway has been ensured and the neonate has been dried and wrapped in a blanket, the nurse places the newborn in the mother's arms. The mother asks, "Is my baby normal?" What is the best response by the nurse? 1 "Most babies are normal; of course your baby is." 2 "Your baby must be all right; listen to that strong cry." 3 "Let's unwrap your baby so you can see for yourself." 4 "Yes, because your entire pregnancy has been so normal."
3 Mothers need to explore their infants visually and tactilely to assure themselves that their infants are healthy. Telling the client that most babies are normal closes off communication with the mother at an opportune moment. A strong cry is not indicative of a healthy newborn. The "normalcy" of the mother's pregnancy is not necessarily correlated with the good health of the newborn.
A primipara delivered 12 hours ago. Although an ice bag has been applied to her perineal area, the client continues to complain of rectal pressure resulting in excruciating pain in the area of the episiotomy. This has also not been relieved by the administration of analgesics. What does the nurse conclude is the cause of the client's pain? 1 A normal response after delivery 2 Low tolerance of pain 3 Hematoma in the perineal area 4 Infection at the episiotomy site
3 Pain becomes excruciating with hematoma development at the episiotomy site because of pressure on surrounding nerve endings. This pain is not relieved by the application of ice because ice only reduces edema formation around the incision. There is no data to indicate that the client has a low tolerance for pain. It is too early to assume that an infection has developed; pyrexia and local signs of infection would support this conclusion.
A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? 1 Obtaining the requested formula 2 Administering the prescribed pain medication 3 Assessing the client's breastfeeding technique 4 Notifying the practitioner of the client's request to switch feeding methods
3 The nurse should assess the client to determine why she is having difficulty with breastfeeding. She may be uncomfortable or in need of assistance with her breastfeeding technique. Immediately providing the formula without assessing the situation does not meet the client's needs at this time. Pain may be a factor in the client's frustration with breastfeeding; however, this should be determined through the assessment process. Notifying the practitioner of the client's request to switch feeding methods is premature. It is the nurse's responsibility to assess the situation and arrive at a solution in collaboration with the client.
A client is being discharged after a first-trimester aspiration abortion. Which statement indicates to the nurse that the client has understood the instructions? 1 "I'll be able to have sex in 4 or 5 days." 2 "I can switch from sanitary pads to tampons after 24 hours." 3 "I can expect my menstrual period to start again in 2 to 3 weeks." 4 "I need to call you if I have to change my pad more than once in 2 hours."
4 Having to change a pad more than once in 2 hours indicates that the bleeding is excessive, and the primary healthcare provider should be notified. Although instructions vary among primary healthcare providers, sexual intercourse usually may be resumed in 1 to 3 weeks and tampons are contraindicated for 3 days to 3 weeks. The menstrual period usually resumes in 4 to 6 weeks.
Before teaching a client about breastfeeding, which information regarding hormonal influences should the nurse fully understand? 1 A high level of progesterone stimulates the secretion of oxytocin. 2 A high level of estrogen stimulates the secretion of lactogenic hormones. 3 Milk secretion is under the control of postpartum hormones starting immediately after birth. 4 Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex.
4 Several factors influence the secretion of oxytocin and the let-down reflex; these include suckling; nipple stimulation; sexual activity; and thoughts, sight, and/or odor of the infant. Progesterone does not stimulate the secretion of oxytocin. A high level of estrogen inhibits anterior pituitary gland secretion of lactogenic hormones. Milk secretion is under the control of postpartum hormones, but it starts on the third or fourth day after birth. Colostrum, secreted during the first 2 postpartum days, is under the control of the pregnancy hormones.