Parent Child EXAM 2 (Chapters 4, 9, 11, 12, 13, 15, 16, 17, 18, 19, 23, 24, 25, 26, & 27)
The injection of a local anesthetic to block specific nerve pathways is referred to as:
Regional block
A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?
Assess for pedal edema
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:
Assess the rate of flow of the oxytocin infusion
A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms?
If rhythmical, they could indicate preterm labor
The purpose of a circulatory shunt, such as the ductus arteriosus, is to:
Permit oxygenated blood to supply the most important fetal organs
A preschooler, receiving home oxygen therapy, is excited about an upcoming birthday. Which statement by the patient's mother indicates that additional teaching on the safety of home oxygen therapy is needed for the occasion?
"I'm baking a cake and we'll have candles"
A pregnant patient scheduled for an amniocentesis asks the nurse how the placenta is not punctured during the procedure. What should the nurse respond to the patient?
"A sonogram to locate it will be done first"
A woman who has had a cesarean birth asks you is she will always need to have cesarean births in the future. Which of the following would be your best response?
"Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth"
While caring for a woman who underwent a primary cesarean section for a breech presentation, she states this baby seems to have so much more mucus than her first baby. Concerned she asks why this has happened. How should the nurse respond?
"Babies born by cesarean section have more respiratory complications because they do not have the benefit of having the mucus in their lungs removed by the pressure experienced in the birth canal"
During her first prenatal visit, a woman 18 weeks pregnant reports she did not realize she was pregnant and continued to take her birth control pills. She is concerned about their effects on her baby. Which of the following would be the best response to her concerns?
"Because of concerns about the estrogen exposure to the baby, we will monitor the fetal development"
A woman whose fetus at 30 weeks of pregnancy is failing to thrive in utero is told her physician wants to deliver the baby by cesarean birth today. She asks the nurse why this would be preferred to a vaginal birth. Which of the following would be your best response?
"Cesarean birth will reduce pressure on the immature head"
Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit?
"Have you had any urinary tract infections?"
A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What is the nurse's best response to her concerning this choice?
"I respect your preference whether it is to have medication or not"
The nurse is instructing a postpartum client on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective?
"If drainage changes from clear to bright red, I am to call the doctor"
The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective?
"I should plan to return to my full-time job after 6 weeks"
A woman is admitted to a labor unit in active labor. Which assessment would alert you to the possibility that she may have the difficulty accepting this child?
"I want this baby to be a boy"
A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching?
"I wear knee-highs rather than pantyhose"
The nurse is assessing a patient for potential home care. Which patient statement indicates that the patient will be able to take medication that is prescribed for three times a day?
"I will take one pill before breakfast, before lunch, and before dinner"
Gynecologic health is an important part of a woman's health history. Which statement best illustrates the way to begin a menstrual history?
"I'd like to ask you some questions about your menstrual periods"
A woman's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best?
"It relieves pressure on the fetal head"
The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which patient statement indicates that the nurse's efforts have been successful?
"It was so nice to not have to wait long in the waiting room"
A nurse is 5 weeks pregnant and works on a care area where chemotherapy is administered to patients. Which statement indicates that this nurse needs additional health teaching about avoiding teratogens during pregnancy?
"Latex gloves irritate my hands, so I don't use them"
A nurse is providing care to a woman early in her pregnancy. The woman is scheduled for a sonogram to confirm the presence of the gestational sac. Which information would the nurse include when teaching the woman about this test?
"Make sure to drink a large amount of fluid prior to the study"
A patient who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births?
"Not if you fulfill the criteria for vaginal birth after cesarean"
A woman's physician has suggested that she use patient-controlled analgesia for pain relief after a cesarean birth. She asks the nurse if this will be effective. Which of the following would be the nurse's best response?
"Not only will it be effective, but it also will reduce the amount of narcotic needed"
A pregnant woman enjoys exercising at a local health spa once a week. Which comment would lead the nurse to believe she needs additional health teaching?
"Nothing feels nicer than a hot sauna after exercise"
A pregnant patient is concerned that the baby is going to drown in the uterus because of the fluid. What should the nurse respond about the fetal respiration?
"Oxygen is provided to the baby through the placenta"
The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed?
"Pain with urination is expected during pregnancy"
The nurse has completed teaching on total parenteral nutrition therapy for the parents of a 3-year-old client who will be receiving therapy at home. Which statement by the mother indicates that reteaching is necessary?
"She can still take her bubble baths every day just like normal"
The nurse teaches the importance of avoiding nonessential substances to a young adult female who is 6 weeks pregnant. Which patient statement indicates that teaching has been effective?
"Smoking is bad for me and my baby"
A woman refuses to have an epidural block because she does not want to have a spinal headache after birth. What would be the nurse's best response?
"Spinal headache is not a usual complication of epidural blocks"
A mother asks you how she can judge that her infant is receiving sufficient breast milk. What would be the most appropriate response?
"The infant should gain weight and have six wet diapers daily"
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?
"The injection is given in the space outside the spinal cord"
The spouse of a pregnant patient is concerned about the risk of paralysis from an epidural block being used during labor. How should the nurse respond to the spouse's concern?
"The injection is given in the space outside the spinal cord"
A new mother is concerned that she will not have enough breast milk because of small breasts. What should the nurse respond to the mother?
"The size of breasts does not impact the amount of breast milk that is made"
A woman who has small breasts is afraid that she will not have enough breast milk. Which of the following is the nurse's best response to this?
"This is a common concern. The size of breasts, however, does not reflect the number of milk glands present"
The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problems?
"We will need to plan for special care to help with learning disabilities"
The nurse is explaining to a school-age child the need to soak the hands twice a day to help with an infection. Which teaching should the nurse provide that would be appropriate for the client's cognitive level?
"Would you like to sit in the chair or stay in bed to soak your hand?"
During the interview portion of her first prenatal visit, a woman reports she thinks she may have a vaginal infection. When questioned, she reports the discharge is thick, greenish-yellow, and she is very uncomfortable. She reports she thinks it is "yeast." How should the nurse reply?
"Yeast is usually a thick, cheesy, white discharge so we will evaluate it during the pelvic exam"
During a physical assessment, the nurse palpates a pregnant patient's fundus at the level of the umbilicus. What statement should the nurse make to the patient about this assessment finding?
"You are at 20 weeks of your pregnancy"
A client who is in the transition phase reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the meperidine. How should the nurse respond to her request?
"Your stage of labor makes giving another dose unsafe"
With the administration of oxygen, a preterm infant's PaO2 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity?
100 mm Hg
On the third day postpartum, which temperature is internationally defined as a postpartal infection?
100.4 degrees F (39.1 degrees C)
A newborn is being breastfed. To evaluate nutritional adequacy, you should be aware that breast milk contains an average of how many calories?
20 calories per ounce
The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weights 8 lb. How much formula should the nurse teach the parents to provide each day?
20 to 24 oz
The nurse is preparing formula for a preterm infant? Which type of formula will most likely be prescribed for this patient?
22 calories per ounce
A woman of normal weight asks you what an ideal weight gain is during pregnancy. Which of the following would be your best answer?
25 to 35 pounds is ideal
When caring for a newborn several hours after birth, the nurse assesses the newborn's respiratory rate. In a normal newborn, this would be:
30 to 60 breaths per minute
The nurse is instructing a pregnant to consume a diet high in complete proteins. Which food item should the nurse recommend as an example of a complete protein?
A boiled or fried egg
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
40 mg/100 mL whole blood
Which of the following correctly identifies the daily caloric requirement per pound for a newborn?
50 to 55
A pregnant woman tells you that she does not drink much fluid daily. How many glasses of fluid would the nurse recommend that the woman ingest daily during pregnancy?
6
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:
7 to 10
Dilation follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement?
8 to 10 cm
A preterm infant born at 32 weeks' gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best?
A 24 cal/oz infant formula
You encourage a pregnant woman to eat a diet high in complete protein. Assuming she likes all of the following foods, which of them would you recommend as a source of this for her?
A boiled or fried egg
A pregnant patient has a history of genital herpes lesions and has experienced outbreaks periodically throughout the pregnancy. What should the nurse instruct the patient regarding this virus if lesions are present at the time of delivery?
A cesarean section will be advised at the time of birth
The nurse evaluates a family to see if they are a good candidate for home care for a sick child. Which factor would be most important to see in their home or of the family?
A dedicated home-care provider
Suppose a patient has several large dogs that you are concerned have fleas. Where would you plan to sit to interview the patient during a home visit?
A kitchen chair
A woman develops a pathologic reaction ring during labor. On assessment, you would expect to find its appearance as which?
A line of indentation over the lower abdomen
During a home visit, the nurse determines that a family is functioning in a healthy manner. Which behavior did the nurse observe to make this determination?
A mother states she has grown up since giving birth to her children
At midpoint during pregnancy, you review beginning signs of labor with a patient. One of the beginning signs of labor you would review is
A sudden gush of clear fluid from the vagina
The fetal-assessment technique of a rhythm strip refers to:
A tracing of fetal heart rate and pattern
The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care?
A woman may spend time thinking about what is happening to her
Which of the following women most likely will not be a candidate to attempt a vaginal birth after having had a previous cesarean section?
A woman who had a cesarean section because of cephalopelvic disproportion
A nurse is reviewing the medical records of several pregnant women who come to the center for care. Which woman would the nurse most likely identify as being at greatest risk for nutritional deficiency during pregnancy?
A woman with a 1-year-old son
After delivery of the placenta, a patient's uterus is sluggish to contract. What should the nurse prepare to do to assist the patient at this time?
Administer oxytocin as prescribed
A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?
Administer oxytocin diluted as a "piggyback" infusion
A newborn is prescribed to receive vitamin K 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn?
Administer the medication into the anterolateral muscle
The nurse is caring for a patient recovering from a cesarean birth. Which assessment should the nurse make a priority for this patient?
Abdominal texture
When examining a newborn for developmental hip dysplasia, which motion would the newborn's hip be unable to accomplish?
Abduction
A newborn is scheduled for casting to correct a talipes disorder. The nurse would advise her parents that the cast will extend:
Above the knee
A postpartum patient has a swollen area of purplish discoloration in the perineal area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this patient?
Acute pain
The nurse is planning nutritional instructions for a pregnant patient who is a Mexican immigrant. On which areas should the nurse focus when preparing teaching for this patient? (Select all that apply)
Add fruits rich in vitamin C Increase the intake of dairy products Reduce the cooking time of vegetables Limit the amount of added animal fat in foods
A woman is in labor with her second child. She knows that she will want an epidural anesthesia and she has already signed her consent form. What must the nurse do before the woman receives the epidural?
Administer a fluid bolus through the IV line to reduce the risk of hypotension
A pregnant patient received a narcotic analgesic 2 hours before delivery. The newborn is lethargic and difficult to arouse. What should the nurse prepare to do to help this newborn?
Administer naloxone hydrochloride
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
Administer oxygen by mask
A newborn is diagnosed with a meconium plug. Which intervention should the nurse prepare to provide to help resolve this health problem? (Select all that apply)
Administration of a barium enema Administration of a gastrografin enema Administration of 5 mL of saline enema Rectal instillation of acetylcysteine
A postpartal woman has a fourth-degree perineal laceration. Which of the following physicians orders would you question?
Administration of an enema
What advice should the nurse provide to a pregnant client who admits to continuing to drink alcohol 1 to 2 times a week?
Alcohol should not be consumed during pregnancy
When teaching a woman about ingesting drugs while breastfeeding, which of the following statements is most accurate?
Almost all drugs are excreted to some extent in breastmilk
At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?
Alveolar collapse on expiration
Amniotic fluid does not grow stagnant because:
Amniotic fluid is constantly formed by the amnion
The nurse is concluding her initial visit with a client 28 weeks pregnant on bedrest for premature rupture of membranes. What information should the nurse consider when determining the timing of the next home visit?
Amount of supervision and health education needed by the client
Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?
An absence of lochia
A woman in early pregnancy asks you why she has palmar erythema. Your reply would be based on the principle that palmar erythema is most likely caused by which of the following?
An increased estrogen level
All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be the most likely to develop hypoglycemia?
An infant who had difficulty establishing respirations at birth
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which actions by the nurse should be implemented first?
Assess the woman's fundus
Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication?
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings
The home care nurse visits a Hispanic pregnant client who speaks very little English. At this visit her husband, who is fluent in English, is not present. Which intervention is most appropriate for the nurse to do?
Call for a telephone interpreter and conduct the visit
When measuring the diagonal conjugate of a woman's pelvis, the distance between which anatomic landmarks would be used?
Anterior surface of the sacral prominence and the anterior surface of the symphysis pubis
Which of the following would you suggest to a pregnant woman who follows a vegetarian diet?
Anticipate needing a vitamin B12 supplement during pregnancy
A pregnant patient planning for labor is asking questions about pain control options. What should the nurse explain about pain control during labor?
Any medication should have maximum effect for the patient and minimal effect on the fetus
During a home visit, a new mother tells the nurse that her nipples are sore from breast-feeding. What should the nurse instruct the mother at this time? (Select all that apply)
Apply lanolin to nipples after air exposure Expose the nipples to air so the nipple dries Position the baby differently for each feeding Massage a few drops of breast milk to the areola
What is the most effective way for a nurse to assess a woman's usual food intake during her pregnancy?
Ask her to describe her intake for the last 24 hours
What advice would you give to a woman who is 4 months pregnant and owns a cat?
Ask someone else to change the cat litter
The nurse is preparing to assess the nutritional status of a patient who is 8 weeks pregnant. What is the most effective way for the nurse to assess the patient's food intake thus far in the pregnancy?
Ask the patient to describe intake for the last 24 hours
The nurses assists while a pregnant patient has an amniotomy. Which action should the nurse take immediately at the conclusion of this procedure?
Assess fetal heart rate
Which precaution should the nurse take with a pregnant woman following an amniocentesis?
Assess fetal heart rate and possible uterine contractions
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?
Assess fetal heart rate for fetal safety
During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs?
Assess fetal heart rate for fetal safety
A postpartal woman has a history of thromophlebitis. Which action would help the nurse determine if she is developing this postpartally?
Assess for calf redness and edema
A pregnant patient is experiencing leg cramps. What should the nurse include in the patient's teaching plan as a relief measure? (Select all that apply)
Avoid full leg extension Elevate lower extremeties
A pregnant patient is experiencing a vaginal discharge and wants to douche. What should the nurse instruct the patient about this health practice?
Avoid routine douching
The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is:
Caused by his mother's hormones
The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?
Baby sleeps with the mother in bed
In providing culturally competent care to clients, the home care nurse should assess health care practices. What should be included in the home care nurse's assessment? (Select all that apply)
Barriers to health care Cultural practices Health-promotion behaviors Education level
A postpartum patient is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the patient about this medication? (Select all that apply)
Be sure to engage in activity to aid in intestinal motility This medication works the best when a high-fiber diet is consumed Take each dose of the medication with a full glass of water or juice
The nurse is preparing to obtain a health history from a client with pre-eclampsia who is at home. In which area should the nurse conduct the assessment?
Bedroom, where it is quiet and private
A nurse is teaching a group of pregnant women about the importance of good nutrition during pregnancy. After describing the B vitamins, the nurse determines that the teaching was effective when the group states which food as the best source of vitamin B12?
Beef
A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?
Both the mother and infant have identification bands that need to match
A new mother asks the nurse to explain the difference between breastfeeding and formula when feeding a newborn. What should the nurse respond as an advantage of breastfeeding for the infant?
Breast milk contains antibodies and decreases the possibility of gastrointestinal illnesses
Which of the following is an advantage of breastfeeding for the infant?
Breast milk contains antibodies and thus decreases the possibility of gastrointestinal illnesses
On the first day postpartum, a new mother is concerned that her milk has not yet "come in." The nurse would explain to her that:
Breast milk normally comes in on the third or fourth postpartum day
A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time?
Breast-feeding can continue
The nurse is preparing a seminal on breastfeeding for a group of pregnant clients. Which information should the nurse include during this seminar?
Breastfeeding enhances bonding with the infant
Which of the following statements is true about breastfeeding?
Breastfeeding offers a good chance for bonding with the infant
The nurse is instructing the parents of a preterm infant about the care the infant will receive within the neonatal intensive care unit. What should the nurse include when teaching the parents at this time? (Select all that apply)
Bring in a small toy to be placed in the baby's bassinette Coordinate the times to visit the baby with the primary nurse Ask the nurse to explain equipment and the purpose for their use Write down the name of the baby's primary nurse and primary care provider
An infant is prescribed oxybutynin chloride for neurogenic bladder. What should the nurse instruct the parents about this medication?
Check the child frequently for sweating
A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that:
Chest rises with each bag compression
A postpartal woman is concerned that her abdomen is extremely lax. Which exercise would the nurse suggest she start on the second day pospartum to tighten her abdominal muscles?
Chin-to-chest
On inspecting a newborn's abdomen, which finding would you note as abnormal?
Clear drainage at the base of the umbilical cord
The nurse is evaluating care provided to a patient giving birth to her first child. Which outcome regarding labor indicates that care has been effective?
Client achieved 4 cm of dilation after 7 hours of labor
The home care nurse is visiting a client and family for the first time. Which initial action can the nurse take to build trust with the client and family?
Communicate in an organized and professional manner
A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history?
Conduct an interview in a private room to obtain her health history
The nurse is concerned that a new mother is ambivalent about the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn at this time?
Contact the Social Service department
A pregnant woman tells you that she wants to avoid saturated fat by using vegetable oil. What is another advantage of vegetable oil?
Contains linoleic acid
The nurse is assisting a new mother begin beastfeeding. Which action is the most appropriate for the nurse to take at this time?
Encouraging her to lie on her side and help the baby become wide awake by talking to him
A pregnant woman is asked to observe fetal movements as a fetal assessment technique. The nurse would instruct her to:
Count fetal movements for 1 hour at the same time each day
A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method?
Counterirritation stimulation blocks pain from traveling to the spinal cord
The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases?
Creases on two-thirds of the foot
The physician of a patient in labor decides that an emergency cesarean birth is required to safely deliver the fetus. When preparing the operating room suite for this procedure, which medications should the nurse ensure are available for possible use? (Select all that apply)
Diazepam Ephedrine Lactated Ringer's solution
During a routine health visit, the mother of a 6-month-old baby mentions that she would like to begin weaning the baby from breast-feeding. What teaching should the nurse provide to the mother at this time?
Discontinue gradually by omitting one breast-feeding session a day
When entering the second phase of labor, a patient tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the patient at this time?
Decision conflict related to the use of analgesia during labor
Why are postpartal women prone to urinary retention?
Decreased bladder sensation results from edema because of pressure of birth
While conducting the first prenatal health history visit, the nurse learns that a pregnancy patient is taking various herbal remedies and over-the-counter medications for minor ailments. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time?
Deficient knowledge regarding exposure to teratogens during pregnancy
A woman in early pregnancy is concerned because she is nauseated every morning. Which measure would be best to help relieve this?
Delay breakfast until midmorning
After an hour of administering oxytocin intravenously, the nurse assesses a woman's contractions to be 80 seconds in length. The nurse's first action would be to:
Discontinue the oxytocin infusion
A pregnant patient is scheduled for an abdominal ultrasound. What should the nurse instruct the patient about this procedure?
Drink a glass of water every 15 minutes starting 90 minutes before the procedure
The nurse is preparing a teaching plan for a patient recovering from a cesarean birth. What should the nurse instruct the patient to help improve stamina and energy after the procedure?
Drink at least six glasses of fluid each day Rest twice a day for at least one-half hour each time
A patient enjoys exercising and wants to know if it can continue to be done while pregnant. What should the nurse instruct the patient about exercising at this time? (Select all that apply)
Drink plenty of liquids to prevent dehydration Limit strenuous exercise to no longer than 20 minutes Warm up for 5 minutes by walking or cycling on low resistance Avoid exercises that require jumping or rapid changes in direction
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:
Ductus arteriosus remains open
A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?
Encourage to continue breast-feeding
A woman who is 4 months pregnant has pyrosis. Which suggestion would the nurse give her?
Eat small meals and do not lie down after meals
On what day during pregnancy does the embryo implant on the uterine surface?
Eight days after ovulation
The nurse is explaining the process of fertilization to a patient who has just learned of being pregnant. On which day during pregnancy should the nurse explain that the embryo implants on the uterine surface?
Eight to 10 days after fertilization
Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms?
Electrical impulses are created that interfere with nerve transmission
On the fourth day postpartum, a woman develops breast engorgement. Which measure would be best to recommend to her as a means of alleviating this problem?
Encourage her to continue regular breastfeeding
The nurse manager of a postpartum care area is planning educational sessions for the nursing staff to support the 2020 National Health Goals for postpartum care. Which information should be included in this staff training? (Select all that apply)
Encourage postpartum patients to participate in breast-feeding Provide information on reproductive life planning if requested Explain the importance of close observation to detect postpartum maternal hemorrhage
The nurse caring for pregnant patients is identifying interventions to support the 2020 National Health Goals regarding pain relief during labor. Which interventions support these goals? (Select all that apply)
Encourage pregnant patients to prepare for childbirth by attending classes Review the different breathing techniques that help with pain control during labor Explain the various complementary and alternative therapies to help with pain control
The prevent thrombophlebitis following a cesarean birth, which of the following would be most important to implement?
Encourage the woman to ambulate
A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?
Ensure that the infant is kept warm
Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management?
Episodes of double vision
A patient in labor with chronic back pain tells the nurse about taking a dose of hydrocodone/acetaminophen (Vicodin) for labor pain prior to coming to the hospital. What should the nurse prepare to do once the fetus is delivered? (Select all that apply)
Evaluate the fetus for withdrawal symptoms Inform the physician so that liver effects can be monitored
A pregnant teenager is not certain that she will like home care because she is afraid she will feel lonely. The nurse should suggest that:
Everyone could eat together
The nurse is preparing teaching for the parents of a newborn with a newly placed ventriculoperitoneal shunt. What should the nurse include in this teaching? (Select all that apply)
Expect to have the shunt replaced as the child grows Examine the site every day for signs of swelling or redness Notify the health care provider if the child develops a fever Observe the child for signs of increased intracranial pressure
A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:
Expiratory grunting
A woman who began breastfeeding develops sore nipples. The nurse bases her response on which of the following?
Exposing her nipples to air after each feeding should help
A pregnant woman experiences frequent leg cramps. Which measure would the nurse include in her teaching plan to provide her with relief?
Extending her knee and dorsiflexing her foot
The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? (Select all that apply)
False labor contractions are irregular False labor contractions do not increase in duration, frequency, and intensity
After learning about the need for a cesarean birth, the pregnant patient begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the patient needs at this time?
Fear related to impending surgery
A primapara woman, 30 weeks' gestation, has no family support and frequently calls the health care provider's office with questions. Which report by the woman would alert the nurse that she may be having a complication related to the pregnancy and needs to come to the clinical today for further assessment?
Feeling of achy, cramping in vaginal area accompanied by bleeding that has saturated 1 pad/hour
As a woman enters the second stage of labor, which would the nurse expect to asses?
Feelings of being frightened by the change in contractions
How does a woman who feels in control of the situation during labor influence her pain?
Feelings of control are inversely related to the client's report of pain
During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding?
Fetal heart rate declining late with contractions and remaining depressed
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?
Fetal heart rate declining late with contractions and remaining depressed
A nonstress test is an assessment test based on which phenomenon?
Fetal heart sounds increase in connection with fetal movement
On an Apgar evaluation, how is reflex irritability tested?
Flicking the soles of the feet and observing the response
The fetus of a woman in labor is in a vertex presentation and at a -1 station. The nurse would interpret this to mean that the fetal head is:
Floating
A woman asks the nurse if she can take an over-the-counter vitamin pregnancy rather than her prescription prenatal vitamin. A chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition is:
Folic acid
The nurse is planning to instruct a patient who is 12 weeks pregnancy on interventions to stop smoking. What should the nurse include in these instructions? (Select all that apply)
Following a smoking cessation plan Ask a friend to help with smoking cessation actions Ask the physician if a smoking cessation medication can be used
When examining a newborn's eyes, the nurse would expect which assessment?
Follows a light to the midline
The nurse is explaining the process of breast milk production with a client pregnant with her first child. What should the nurse include when providing this teaching? (Select all that apply)
For the first 3 to 4 days, the breast milk is colostrum True breast milk comes in by the 10th day after giving birth
When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel?
Fundus two fingerbreadths below umbilicus and firm
A pregnant patient experiencing exacerbation of asthma is prescribed home care. The nurse is planning to assess the patient's community for resources. On which areas will the nurse focus this assessment? (Select all that apply)
Health Environment
While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply)
Grunting Nasal flaring Intercostal retractions Increasing respiratory rate
A husband asks if he can view his wife's cesarean birth? Which of the following reflects a modern policy on this subject?
He can view it if her chooses, especially because his wife will be awake
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?
Head elevated, grasping knees, breathing out
A client who is at 30 weeks' gestation is prescribed bed rest and home care. Which skills should the nurse anticipate providing when making the home care visits with the client? (Select all that apply)
Health teaching Monitoring vital signs Monitoring fetal heart rate Administering medication
While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time?
Health-seeking behaviors related to care of newborn
A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her?
Health-seeking behaviors related to ways to relieve discomforts of pregnancy
A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge?
Hearing assessment
The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?
Her blood pressure is below 140/90 mm Hg
Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution?
Her uterus is at the level of the umbilicus
The nurse assesses that a fetus is in a breech presentation. Where would you auscultate for fetal heart sounds?
High in the abdomen
The nurse is checking a newborn for the presence of Ortolani maneuver and Barlow sign. For which health problem are these assessments used?
Hip dysplasia
A nurse is caring for a child with a tracheoesophageal fistula. Which finding during pregnancy would have caused the nurse to suspect this might be present?
Hydraminos
For which condition would the nurse commonly assess in an infant following surgery for a myelomeningocele?
Hydrocephalus
While reviewing a newborn's hospital record, which of the following would be most important for you to locate?
If he breathed spontaneously at birth
A new mother asks you how soon she can breastfeed after delivery. Which of the following would be your best answer (barring unforeseen complications)?
Immediately after birth
The health care provider is reluctant to provide pain medication to a patient delivering a preterm fetus. What should the nurse explain to the patient as the reason for the preterm fetus being more affected by medication?
Inability of the immature liver to metabolize or inactivate drugs
Which of the following supports why a preterm fetus usually is more affected by medication given at birth than a full-term fetus?
Inability of the immature liver to metabolize or inactive drugs
Which assessment finding indicates to the nurse that a newborn has hip subluxation?
Inability of the right hip to abduct
A pregnant patient is concerned that she is allergic to something because her hands have been red and itchy since becoming pregnant. What should the nurse explain as the cause of the patient's symptoms?
Increased estrogen level
If constipation is a problem for a woman during pregnancy, which measure would be best to recommend?
Increased fiber intake
Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which nursing diagnosis is this intervention addressing?
Ineffective thermoregulation related to immaturity
A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2, HR 82 beats/min, RR 18 breaths/min, BP 125/78 mm Hg. How will the nurse interpret the vital signs?
Infection
A patient who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the patient's fluid status during the procedure?
Initial intravenous fluid therapy
A postpartum patient is diagnosed with a vaginal laceration. What intervention will the nurse provide to the patient at this time?
Insert an indwelling urinary catheter
The nurse is concerned that a pregnant patient will have a complication from a medication after a cesarean birth. For which prescribed medications are complications most likely to occur? (Select all that apply)
Insulin Anticoagulant Antihypertensive Antianxiety agent
When teaching the pregnant patient about self-medicating for pain during labor, why did the nurse instruct the patient to avoid taking acetylselicylic acid (aspirin)?
Interference with blood coagulation with increased risk of bleeding in mother or infant
Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor?
Interference with blood coagulation with increased risk of bleeding in mother or infant
A nurse is reviewing a journal article about fetal development and the formation of various body systems. When reading about the development of the digestive system, the nurse finds the information related to the developmental abnormality of omphalocele. The nurse demonstrates understanding of this information by identifying which situation as the reason for an omphalocele?
Intestines failed to return to the abdominal cavity during intrauterine life
A postpartal woman is placed on an anticoagulant to prevent further clot formation. She asks the nurse if she will be able to continue breast-feeding. The nurse's best response would be that:
It depends on the type of anticoagulant she is taking
When explaining what will occur during the first prenatal visit physical examination, a pregnant patient asks why a Papanicolaou smear is being done at this time. What should the nurse respond to the patient?
It detects cancer cells of the cervix, vulva, or vagina
Why is a Papanicolaou smear done at the first prenatal visit?
It identifies abnormal cervical cells
A new mother is distraught because the baby has a white discharge coming from the breasts. What should the nurse explain to the mother about this discharge?
It is caused by the mother's hormones
Which information is true of home care as a whole?
It is increasing because new technology makes so many procedures available in the home
A patient who is 28 weeks pregnant is demonstrating signs of placental insufficiency. The health care provider prescribes betamethasone. When teaching the patient about this drug's purpose, which information would the nurse include?
It potentiates the formation of surfactant
In terms of planning care, why is the development of a pathologic retraction ring important?
It precedes uterine rupture
A woman reports to the clinic to have her IUD checked. During the visit it is determined she is 6 weeks pregnant. How will the presence of the IUD be handled?
It will be removed to allow the pregnancy to grow
The nurse instructs a pregnant client who is at home on bed rest to drink at least eight glasses of fluid each day. What would be the best method to encourage the client to drink this amount?
Keep a pitcher of fluid readily available on a bedside table
A postpartum client with thrombophlebitis states that her leg is very painful. Which nursing instruction is most appropriate to decrease the pain?
Keep covers off the leg
A woman is scheduled to have an epidural anesthesia for a cesarean birth. Which of the following would the nurse anticipate including in the preoperative plan of care while she waits for the anesthetic?
Keeping her turned on her side
When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?
Keeping it dry
The nurse is preparing to make a home visit to admit a new client to services. Which actions should the nurse take to ensure personal safety? (Select all that apply)
Keeping the gas tank of the car full Parking the car in a well-lit area Using a map to avoid getting lost in a strange neighborhood Informing the agency of the estimated arrival time and expected return
An infant with hydrocephalus is scheduled to have a ventriculoperitoneal shunt inserted. Immediately following the procedure, which nursing action would best prevent decompression from excessive cerebral spinal fluid flow?
Keeping the head of the infant level with the body
After assessment, the nurse determines that a pregnant patient's fetus has a face presentation that is pointing to the patient's left side with transverse pointing. How should the nurse document this assessment finding?
LMT
A pregnant woman works as a secretary at a large corporation. She states that she wants to take a leave of absence from work for pregnancy but is afraid she will lose seniority standing because of this. You would advise her that
Legally, her employer cannot penalize her this way
A pregnant patient is directed to perform a daily fetal movement count. What should the nurse instruct the patient about this count? (Select all that apply)
Lie down to do the count after eating a meal Count fetal movements until a total of 10 are counted and record the time
A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?
Lie on her side so she is comfortable
Which finding would the nurse expect to assess in an infant with hypoglycemia?
Limpness or jitterness
A pregnant patient is planning travel to a foreign country as part of a work assignment and needs immunizations. What should the nurse instruct the patient about immunizations while pregnant?
Live virus immunizations are contraindicated while pregnant
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:
Place a hand gently on the fetal head to guide birth
The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?
Lochia rubra
After delivery, a patient diagnosed with postpartal gestational hypertension. What care will the nurse provide to this patient? (Select all that apply)
Maintain on bed rest Monitor urine output Administer magnesium sulfate as prescribed Administer antihypertensive medication as prescribed
After delivery, a patient is diagnosed with placenta succenturiata. For what procedure should the nurse prepare this patient?
Manual removal of accessory lobes
Which action could the nurse initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position?
Massage her lower back
The following are nursing measures commonly offered to women in labor. Which nursing intervention probably would be most effective in applying the gate-control theory for relief of labor pain?
Massage the woman's back
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?
Mastitis
18-year-old pregnant woman asks the nurse why she has to have a routine alpha-fetaprotein serum level drawn. The nurse explains that this:
May reveal chromosomal abnormalities
Which action would be most important to do for an infant following surgery for myelomeningocele?
Measure a daily head circumference
Which of the following would be a danger signal of labor for a woman in labor?
Meconium-stained amniotic fluid
Which food below is not a good source of iron?
Milk
The nurse is evaluating a mother's ability to catheterize her 2-year-old son. Which observations indicate that teaching has been effective? (Select all that apply)
Mother washes hands using warm, soapy water Mother washes around the child's urinary meatus with warm, soapy water
A pregnant patient tells the nurse that she hopes the baby is not in the breech position because she has heard that this causes difficult labor. What should the nurse include when explaining the reasons for this presentation to the patient? (Select all that apply)
Multiple fetuses Fetal birth defects Lax abdominal muscles Fetal age less than 40 weeks
When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heart rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would be to:
Place her in a knee-chest position
During a home visit, the nurse begins teaching on medication safety in the home. What should the nurse include in these instructions? (Select all that apply)
Never take medication in front of children Use a reminder sheet and cross off when a medication has been taken Drink a full glass of water with pills to ensure they reach the stomach Keep all medication in a safe place above the height for a child to reach
The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective?
Newborn is placed on the back to sleep
The nurse is evaluating a new mother's ability to breastfeed her infant. Which criteria indicate that the mother is able to breastfeed independently? (Select all that apply)
Nipples are everted Breasts are soft and nontender Baby swallows spontaneously and frequently
After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting. What should the nurse do?
Notify the physician and stop the infusion
When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need?
Nutrition
After cleft palate repair at 18 months, a child will begin a liquid diet. Which method of initiating the diet is best?
Offer the child sips from a small glass
When discussing rest and sleep with a pregnant woman, the nurse would discuss which position to use for napping?
On her side with the weight of the uterus on the bed
To administer oxygen by bag and mask to a newborn, you would position the baby
On the back with the head slightly extended
It would be best to place an infant with a myelomeningocele in which position prior to surgery?
On the stomach (prone)
On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is:
One-fourth his total length
A patient is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient?
Oxytocin therapy
After pelvic measurements, a patient who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this?
Passageway
The nurse has identified the diagnosis of imbalanced nutrition for a pregnant patient. Which assessment data did the nurse use to identify this diagnosis for the patient?
Patient does not want to gain any weight while pregnant
A postpartal patient is being treated for a separated symphysis pubis. Which outcome should the nurse identify when planning care for this patient?
Patient has coordinated child care assistance
The nurse provides instructions to a patient with hyperemesis gravidarum. Which outcome indicates that teaching has been effective?
Patient is able to ingest a regular diet after progressing through clear liquids and soft foods
The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective?
Patient is chatting on the telephone with a friend
A pregnant patient nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the patient during the delivery process?
Patient uses breathing techniques to control anxiety and pain during labor
The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2020 National Health Goals for the newborn? (Select all that apply)
Place the infant on the back to sleep Continue to breast-feed the baby until age 6 months Do not provide the baby with a bottle wile falling asleep
When palpating for fundal height on a postpartal woman, which technique is perferable?
Placing one hand at the base of the uterus, one on the fundus
A newborn weighed 7 lb, 3 oz at birth. Based on this birth weight, which procedure would be necessary for you to carry out?
Plotting his weight on a gestational age graph
A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning?
Positive end-expiratory pressure to increase oxygenation
At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse classify this neonate?
Postterm
A primigravida whose baby is presenting breech is scheduled to have a cesarean birth. Which of the following would you prepare her for postoperatively?
Presence of an indwelling catheter
Assessment for surfactant level is a primary estimation of fetal maturity. The purpose of surfactant is to:
Prevent alveoli from collapsing on expiration
On the second day after a surgical repair for a cleft lip, which of the following would be most important?
Preventing crust formation on the suture line
The nurse is teaching a patient in the first trimester of pregnancy about the importance of folic acid in the diet and how folic acid supplements might be beneficial. For which reason is the nurse teaching the patient about this vitamin?
Prevents neural tube disorders in the developing fetus
The nurse visits a pediatric client at home for complications of sickle cell. Upon entering the home, the nurse notices a significant number of candles being burned, statues surrounding the client, and herbs around the room. What is the most appropriate response by the nurse?
Proceed with the visit
The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit. For what will the nurse test this patient's urine? (Select all that apply)
Protein Glucose Bacteria White blood cells
Which two tests are generally performed on urine at a prenatal visit?
Protein and glucose
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?
Provide a mobile the child can see no matter how the child is turned
The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this patient's plan of care? (Select all that apply)
Provide audio stimulation with use of music Stop procedures if the infant shows signs of distress Provide a nest with blankets to provide a sense of security Provide care consistently so the infant develops sleep/wake cycles
Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?
Provide ongoing communication about what is happening
The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior?
Reacting normally to accepting a new child
A parent tells you she found caring for her son at home very difficult at first but now has adjusted. What would be the most appropriate nursing diagnosis for this family?
Readiness for enhanced coping related to home care
A patient who learns of being 9 month pregnant asks the nurse to explain the changes that are occurring with her body. The woman states, "I'm really interested in learning what is happening so I can do the best for my baby." Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time?
Readiness for enhanced knowledge
The nurse is planning a seminar that focuses on the 2020 National Health Goals during pregnancy for patients who are in the first trimester of pregnancy. Which information should the nurse include in this seminar? (Select all that apply)
Refusing alcohol Importance to stop smoking Maintaining health appointments Abstaining from drugs and substances
The nurse is completing the health histories for twin toddlers. Which statement should the nurse make to the mother that focuses on the 2020 National Health Goals?
Remind the mother that the toddlers need regularly scheduled vaccinations
An infant was born after a face presentation. When selecting a nursing diagnosis for the newborn, which body system does the nurse identify as a priority?
Respiratory
A pregnant patient in labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone of the uterus is high, 20 to 25 mm Hg. The patient asks what can be done to make contractions more effective. How should the nurse respond to the patient?
Rest because contractions are hypertonic
A multipara client in labor is having contractions which are 2 minutes apart but rarely over 50 mm Hg in strength; the resting uterine tone is high, 20 to 25 mm Hg. The client asks what she can do to make contractions more effective. The nurse's best response is which?
Rest between contractions
The nurse manager of a labor and delivery unit is reviewing the skill set needed for the nursing staff to meet the 2020 National Health Goals regarding preterm births. Which skills should the manager validate that the nursing staff has to meet these goals? (Select all that apply)
Resuscitation at birth Actions to prevent apnea Identify characteristics of preterm labor Interventions to prevent intraventricular hemorrhage
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
Retracting the foreskin over the glans to assess for secretions
A pregnant client had decided to breastfeed the infant but, after delivery, tells the nurse that formula feeding would be the best choice for her now. What nursing diagnosis should the nurse use to plan this client's care?
Risk for impaired parenting
A newborn with esophageal atresia has just returned from surgery to place a gastrostomy tube. Which nursing diagnosis will the nurse use to plan the care for this patient?
Risk for impaired skin integrity
During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time?
Risk for ineffective breathing pattern related to breathing exercises
A postpartal woman (gravida 1, para 1) asks immediately after delivery if she should request rooming-in with her infant. Your best response would be that:
Rooming-in allows increased maternal-newborn contact
A client the nurse meets in a prenatal clinic states that she has a vaginal discharge and asks about douching. Which rule is safe regarding douching during pregnancy?
Routine douching is not advised
At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk during the pregnancy. Which data from the patient's past illness history does the nurse use to make this decision? (Select all that apply)
Seizure disorder Hypertension for 10 years Previous treatment for gonorrhea
A pregnant patient in labor is being encouraged to push with contractions. In which position should the nurse assist to help the patient at this time?
Semi-Fowler's position with legs bent against the abdomen
A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period?
She did her perineal care independently
Which of the following would you advise a woman about breast self-examination during pregnancy?
She should choose a date each month to do this
Which action would most make the nurse believe that a postpartum woman is accepting a child well?
She turns her face to meet the infant's eyes when she holds her
During a previous prenatal visit, the nurse focused on the importance of adequate nutritional intake with a pregnant patient. Which assessment findings indicate that this teaching has been effective? (Select all that apply)
Shiny hair Smooth tongue Normal muscle reflexes
A postpartal woman is prescribed an antibiotic because of endometritis. Her breast-fed infant should be observed particularly for which of the following?
Signs of thrush and easy bruising
A woman who is two days postpartum has painful hemorrhoids postpartally. Which of the following positions would you suggest she use for resting?
Sims' position
Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?
Sitz baths increase the blood supply to the perineal area
A new mother is ambivalent about breastfeeding and agrees to do it for at least 3 months. What response should the nurse provide to the patient at this time that would support the 2020 National Health Goals?
Six to 1 year of age is the best time frame to support the baby's growth needs
When assessing a newborn's 5-minute Apgar score, how will the nurse determine reflex irritability?
Slapping the soles of the feet and observing the response
A pregnant woman tends to not eat for long periods of time because of her busy work schedule. What process safeguards her fetus from becoming hypoglycemic during this time?
Somatomammotropin helps to regulate blood glucose levels
A woman is concerned that orgasm will be harmful during pregnancy. Which statement is factual?
Some women experience orgasm intensely during pregnancy
A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid balance. What did the nurse assess that supports this nursing diagnosis? (Select all that apply)
Specific gravity of 1.022 Urine output less than 2 mL/kg/hr
The nurse is visiting the family of a newly pregnant patient whose spouse was ambivalent about the pregnancy during the first prenatal visit. Which observation indicates that the spouse is accepting the pregnancy?
Spouse sits with the pregnant patient during the nurse's visit
The nurse manager at a family clinic is identifying ways to address the 2020 National Health Goals for the prevention of birth defects. Which action should the manager encourage all staff to perform when caring for pregnant patients?
Stress the importance of taking prenatal folic acid as prescribed
A 20-year-old woman you see in a prenatal clinical has an accessory nipple. Which of the following teaching points would be most important to make with her?
Such growths deepen in color during pregnancy
During a prenatal appointment, a patient who is 3 months pregnant states she ingests starch because of a craving. What should the nurse respond to this patient?
Suggest a hemoglobin assessment be done
At a prenatal appointment, a woman who is 3 months pregnant confides to you that she ingests starch because of a craving she has had since adolescence. She is now 26 years old. What would be your most appropriate response?
Suggest she have a hemoglobin assessment done because of the association between pica and iron-deficiency anemia
The nurse providing care to patients in the labor and delivery suite desires to support the 2020 National Health Goals to reduce maternal and infant mortality after labor and birth. Which action should the nurse perform to support these goals?
Support laboring patients through the use of controlled breathing techniques
An adolescent who is pregnant asks the nurse which sport would be safe for her to learn during pregnancy. Which activity would the nurse suggest as safe?
Swimming
The nurse is planning a prenatal educational program for a community health center. What information should the nurse include that supports the 2020 National Health Goals for nutrition in pregnancy? (Select all that apply)
Take prenatal vitamins as prescribed Ensure a daily intake of foods high in simple carbohydrates Maintain adequate nutrition before becoming pregnant
To assess the frequency of a woman's labor contractions, the nurse would time:
The beginning of one contraction to the beginning of the next
What is most important to teach parents regarding future management of a ventribuloperitoneal shunt placed in infancy due to hydrocephalus?
The child is likely to outgrow the shunt by school age
The nurse is evaluating the outcome of teaching for a baby born with torticollis. Which observation indicates that teaching has been successful?
The child looks in the direction of the affected muscle
What health teaching would you plan with the parents of a child with a cleft palate following surgery?
The child may have increased episodes of otitis media
The nurse instructs a client who is at 28 weeks' gestation on the correct use of the fetal heart monitor at home. Which observation indicates that teaching has been effective?
The client has a log with the date, time, and number of fetal heart beats counted
A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?
The color of the flow is red
The nurse is teaching a pregnant patient the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor?
The fetal head bends forward onto the chest
A fetus is capable of producing antibodies. The finding of IgM antibodies in an infant at birth implies that:
The fetus contracted an infection during intrauterine life
While conducting Leopold maneuvers, the nurse determines that the fourth maneuver does not need to be done. What information caused the nurse to make this decision?
The fetus is not in a cephalic presentation
The nurse is preparing to assess the duration of contractions for a patient in labor. Which process should the nurse use to time the contractions?
The interval between the beginning and the end of one contraction
On the first day postpartum, a patient who underwent a cesarean section requests pain medication. Which of the following actions should the nurse perform first?
The location of the pain should be assessed
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?
The mother may have difficulty working effectively with contractions
Which statement describes why hypertonic contractions tend to become very painful?
The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells
A newborn is born with a myelomeningocele. Which assessment data is most important to consider when managing care?
The newborn drips urine throughout the shift
The nurse determines that a fetal nonstress test is nonreactive for over 20 minutes. The nurse interprets this result as suggesting which situation? (Select all that apply)
The patient is hypoglycemic The patient is using an illicit drug The patient is smoking while pregnant
During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective?
The patient is not requesting pain medication
A woman having a cesarean birth will have a low cervical incision. Which of the following would you cite as an advantage?
The skin incision will be just above her pubic hair
A newborn infant has loose, yellow stools. Although the infant is healthy, his mother is concerned that this means he is allergic to breast milk. The nurse would explain to her that:
The stools of breastfed infants are normally loose
A woman who professes to be a strict vegetarian voices concerns about her ability to meet the nutritional needs of her fetus. Which concerns should be addressed in this session?
The supplementation of Vitamin B12 should be addressed
Implantation generally occurs at which place on the uterus?
The upper posterior surface
A nurse is providing skilled home care to a pregnant woman. Which situation best describes this concept?
The woman needs daily fetal heart rate monitoring
A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:
This is a normal finding
The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?
This is a technique to prevent the painful stimuli from entering the brain
The laboring client who is at 3 cm dilation and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?
This may prolong labor and increase complications
One type of medicine a patient on home care services could be given with any of the following schedules. Which of the following would be most effective in helping compliance?
Three times a day at 10 am, 2 pm, and 10 pm
The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?
To detect rebound hypoglycemia
A preterm infant is transferred to a distant hospital for care. When her parents visit her, which action would be most important for the nurse to urge them to do?
Touch and, if possible, hold her
A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient?
Transverse narrow
The nurse is caring for a small-for-gestational-age infant born to a drug-dependent patient. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? (Select all that apply)
Tremors Convulsions High-pitched cry Constant movement
A patient in labor has been prescribed an intravenous infusion of 5% dextrose/water. Following insertion of the intravenous line, what should the nurse instruct the patient to do?
Try to forget the fluid line is in place
Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. The nurse's first action would be to:
Turn her on her left side or raise her legs
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
Turn her or ask her to turn to her side
Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first?
Turn onto the left side or raise the legs
During the second stage of labor, a woman is generally:
Turning inward to concentrate on body sensations
On the second day postpartum following a cesarean birth, at which of the following locations would you expect to palpate the woman's fundus?
Two fingers below the umbilicus
Following a cesarean birth, a woman has 3000 mL of intravenous fluid ordered. The nurse anticipates in the plan of care that she will be kept NPO except for minimal ice chips until which time?
Until bowel sounds have returned
When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection?
Up the reproductive tract
The nurse is a community clinic is identifying ways to achieve the 2020 National Health Goals to support prenatal care. Which nursing actions would support the achievement of these goals? (Select all that apply)
Urge female patients to ingest adequate intake of folic acid Recommend pregnant patients attend developmental childbirth classes Provide a play area in the waiting room for the children of patients waiting to be seen Support pregnant patients to achieve the recommended weight gain during pregnancy
A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best?
Use distraction therapy
The nurse is caring for a woman who has had a baby by cesarean birth. Which of the following would be the most important assessment to make?
Whether her abdomen is soft or not
The nurse is assessing a patient in labor. On which complication of labor as identified within the 2020 National Health Goals will the nurse focus?
Uterine rupture
A patient is having a cesarean birth will have a low segment incision. What should the nurse explain to the patient as an advantage for this type of incision?
Vaginal deliveries can occur with future births
A patient in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will be used. What should the nurse do to prepare for this type of delivery? (Select all that apply)
Validate that the cervix is fully dilated Determine that the patient's bladder is empty Ensure that the patient's membranes have ruptured
The nurse is evaluating the fetal health rate rhythm strip and determines that the amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding indicate to the nurse about variability?
Variability is normal
The nurse is caring for an infant born with myelomeningocele. What should the nurse assess in this patient?
Voiding patterns
A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action?
Walk with the nurse the length of her room
A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?
Wash her perineum with her daily shower
When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?
Weak and rapid pulse
A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding?
White plaques in the mouth
An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess?
White sclera showing above the pupils
A woman asks you if she will have any difficulty breast-feeding following a cesarean birth. Which of the following would be your best response?
You will help her find a comfortable position for breastfeeding her infant
