PN 131 Quiz 3 NCLEX Practice Questions

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if the condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2. Uterine tenderness Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. Abdominal pain is present along with uterine tenderness.

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3. Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse.

A client arrives at birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. less pressure on her cervix 2. decreased number of contractions 3. increased efficiency of contractions 4. the need for increased maternal blood pressure monitoring

3. Increased efficiency of contractions

The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? 1. "The cord will fall off in 1 to 2 weeks." 2. "Alcohol may be used to clean the cord." 3. "I should cleanse the cord two or three times a day." 4. "I need to fold the diaper above the cord to prevent infection."

4 The diaper should be folded below the cord to keep urine away from the cord, so a statement by the client that the diaper should be folded above the cord would be incorrect, indicating the need for further instruction. The cord should be kept clean and dry to decrease bacterial growth. Cord care is required until the cord dries up and falls off, between 7 and 14 days after birth. The cord should be cleansed two or three times a day with soap and water or other prescribed agents

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? SATA 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover thew newborn's eyes with eye shields or patches.

4, 5, 6

A nurse determines that which of the following is an appropriate short term goal for a full term, breastfeeding neonate? 1) The baby will regain birth weight by 4 weeks of age. 2) The baby will sleep through the night by weeks of age. 3) The baby will stool every 2 to 3 hours by 1 week of age 4) The baby will urinate 6 to 10 times per day by 1 week of age.

4. By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period.

Which vital sign of a newborn is abnormal 1. Axillary temperature of 37 2.RR of 50 3. BP of 70/40 4. HR of 190

4. hr of 190 -HR should be 110-160

Which signs and symptoms characterize cold stress? Select all that apply. Fever Tachycardia Mottling of the skin Periods of apnea Hyperactivity

Mottling of the skin Periods of apnea Signs and symptoms of cold stress include decreased skin temperature, increased respiratory rate with periods of apnea, bradycardia, mottling of skin, and lethargy.

A a nurse is caring for a newborn immediately following a circumcision using a gomco procedure. Which of the following actions should the nurse implement? a. apply gelfoam powder to the site. B. Place the newborn in the prone position. C. apply petroleum gauze to the site. d. scrub yellow discharge

c. apply petroleum gauze to site -prevents adhesion to diaper

Which statement indicates that an expectant mother understands the diagnosis of placenta previa? "My doctor will not let my pregnancy go beyond my due date before he induces me." "My doctor will monitor for rupture of membranes each week at my appointment." "My doctor will not induce labor at any time during this pregnancy." "My baby will probably come early because of my condition."

"My doctor will not induce labor at any time during this pregnancy." The physician will not induce a patient with this diagnosis. Rupture of membranes is not a primary risk for this complication. This diagnosis does not have a high correlation with preterm births

The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1.Make a loud, abrupt noise to startle the newborn. 2.Stimulate the ball of the foot of the newborn by firm pressure. 3.Stimulate the perioral cavity of the newborn infant with a finger. 4. Stimulate the pads of the newborn infant's hands by firm pressure.

1 The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar pattern). The Moro reflex is present at birth and is absent by 6 months of age if neurological maturation is not delayed. A persistent response lasting more than 6 months may indicate a neurological abnormality. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all the apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin IV infusion 4. Document the findings and continue to monitor the fetal patterns.

1. Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during uterine contractions. Hypoxemia results; administer 8-10 L/minute via face mask.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of barrel chest and acrocyanosis

1. Tachypnea and retractions A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? 1. Applying lotions to exposed newborn skin 2. Assessing skin integrity and fluid status of the newborn 3. Having minimal contact with the newborn to prevent stimulation 4. Advising the mother to limit the newborn's oral intake during phototherapy

2 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Assessing skin integrity and fluid status of the newborn infant is an essential component of phototherapy. Lotions are not used to ensure the therapeutic effect of light exposure in subcutaneous tissue. Contact with the newborn infant is important. Adequate oral fluids are essential to prevent dehydration because diarrhea is a common side effect of therapy. In addition, safe care for the newborn infant during phototherapy requires shielding the eyes with a soft eye shield to prevent retinal damage, keeping the newborn's skin exposed except for the wearing of a diaper, and changing the newborn's position frequently.

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2 The mode of perinatal transmission of human immunodeficiency virus (HIV) to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. HIV-positive clients should be encouraged to bottle-feed their infants per the health care provider's prescription. Frequent hand-washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. The nurse should provide which most appropriate instruction to the mother? 1. Feed the newborn less frequently 2. Continue to breast-feed every 2-4 hours 3. Switch to bottle-feeding the infant for 2 weeks 4. Stop breast-feeding and switch to bottle feeding permanently

2. Continue to breast-feed every 2-4 hours

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs 2. Massage the fundus until it is firm 3. Ask the client to turn on her left side 4. Push on the uterus to assist in expanding clots

2. Massage the fundus until it is firm If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus.

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

3 Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.

A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? 1. "His circumcision will heal within 24 hours." 2. "I should remove the yellow mucus that will form." 3."I will clean his penis with each diaper change." 4."I will give him a tub bath within a couple of days."

3. "I will clean his penis with each diaper change"

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring

3. Increased efficiency of contractions Amniotomy can be used to induce labor when the condition of the cervix is favorable or to augment labor if the progress begins too slow.

A nurse is caring for a client who is receiving Oxytocin/Pitocin to induce labor. The nurse discontinues the infusion if which of the following is noted on assessment of the client? 1. Fatigue 2. Drowsiness 3. Uterine Hyperstimulation 4. Early decelerations of the fetal heart rate

3. Uterine hyperstimulation

The nurse is preparing to care for a newborn receiving photo-therapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4, 5, 6 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further teaching? 1. "I should breast feed every 2-3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breastfeeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Soap is drying and could lead to cracks in the nipples.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Acceleration 3. Early decelerations 4. Variable decelerations

4. Variable decelerations Variable decelerations occur if the umbilical cord is compressed, reducing the blood flow between the placenta and the fetus.

A a nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? 1. Cover the cord with a small gauze square. 2. Trickle clean water over the cord with each diaper change. 3. apply hydrogen peroxide to the cord twice a day. 4. Keep the diaper folded below the cord.

4. keep the diaper folded below the cord -the cord should not be covered because it promotes infection -water should not be applied to cord -cord should be kept clean and dry. hydrogen peroxide not applied to cord

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: A. Uterine atony B. Uterine inversion C. Vaginal hematoma D. Vaginal laceration

A A. Correct: Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. B. Incorrect: Uterine inversion may lead to hemorrhage, but it is not the most likely source of this client's bleeding. Furthermore, if the woman was experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. C. Incorrect: A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. D. Incorrect: A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

With regard to the process of augmentation of labor, the nurse should be aware that it: a. Is part of the active management of labor that is instituted when the labor process is unsatisfactory. b. Relies on more invasive methods when oxytocin and amniotomy have failed. c. Is a modern management term to cover up the negative connotations of forceps-assisted birth. d. Uses vacuum cups.

A Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation.

A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority? a. Placing the woman in the knee-chest position b. Covering the cord in sterile gauze soaked in saline c. Preparing the woman for a cesarean birth d. Starting oxygen by face mask

A The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position, on all fours) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.

Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives? a. Weight gain should be reported to the physician. b. An alternate method of birth control is needed when taking antibiotics. c. If the client misses one or more pills, two pills should be taken per day for 1 week. d. Changes in the menstrual flow should be reported to the physician.

Answer: B When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5-10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

A adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by; a. Return preovulatory basal body temperature b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle c. 3 full days of elevated basal body temperature and clear, thin cervical mucus d. Breast tenderness and mittelschmerz

Answer: C Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle is not significant. Breast tenderness and mittelschmerz are not reliable indicators of ovulation.

A client had a previous cesarean birth. What are the criteria in order to try having a vaginal birth during the second pregnancy? Select all that apply. A. A history of postpartum hemorrhage B. A previous classical vertical incision C. Clinically adequate pelvis D. Previous low transverse incision E. No history of uterine rupture

C, D, E (A vaginal birth is possible after a previous caesarean delivery if the pelvis is found to be adequate to provide room for childbirth. A previous low transverse incision poses less risk of rupture and a vaginal delivery may be possible. A client with no history of uterine rupture would have less risk of uterine rupture during the vaginal delivery. A history of postpartum hemorrhage may not affect the risk associated with a second vaginal delivery in women with a history of first caesarean delivery. A previous vertical incision on the uterus increases the risk of uterine rupture.)

The nurse is monitoring a pregnant client after amniotomy. Which observation would indicate a likelihood of umbilical cord compression? A. The fetal heart rate (FHR) confirms tachycardia. B. The client's vaginal drainage has a foul-smell. C. The client has maternal chills frequently. D. The fetal heart rate (FHR) has variable decelerations.

D (Amniotomy is performed in a pregnant client in order to rupture the membranes artificially. After the procedure, the nurse should closely monitor the FHR. Reduced FHR and variable decelerations in FHR indicate that the client's umbilical cord is compressed. The nurse should immediately inform the primary health care provider of the client's condition. Tachycardia or increased FHR are common manifestations observed after amniotomy. Tachycardia does not require immediate clinical action. Maternal chills and foul-smelling vaginal discharge after amniotomy indicate infection of the ruptured membranes. However, this would not be a reason to expect umbilical cord compression.)

Nurses should be aware that the induction of labor: a. Can be achieved by external and internal version techniques. b. Is also known as a trial of labor (TOL). c. Is almost always done for medical reasons. d. Is rated for viability by a Bishop score.

D A high score (above 6) is predictive of successful labor induction because the cervix has ripened or softened in preparation for labor. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons.

The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is: a. A gravida 3 who has had two low-segment transverse cesarean births. b. A gravida 2 who had a low-segment vertical incision for delivery of a 10-pound infant. c. A gravida 5 who had two vaginal births and two cesarean births. d. A gravida 4 who has had all cesarean births.

D The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine rupture.

What physical characteristic most likely indicates postmaturity? Abundant lanugo Peeling skin Abundant vernix caseosa Thin, transparent skin

Peeling skin The postterm infant is long and thin and looks as though weight has been lost. The skin is loose, especially about the thighs and buttocks. There is little lanugo or vernix caseosa. The skin is dry; it cracks, peels, and is almost like parchment in texture. The nails are long and may be stained with meconium. The infant has a thick head of hair and looks alert.

Which diagnostic test would be used first to evaluate male fertility? Endocrine test Semen analysis Ultrasound Testicular biopsy

Semen analysis is inexpensive and easy to obtain, so it is the first test to evaluate fertility. The others are done, but they are more costly or invasive.

Which patient history and physical information would contraindicate use of oral contraceptives? Select all that apply. Heavy menstrual bleeding Irregular bleeding Undiagnosed menstrual bleeding Positive pregnancy test One week postpartum and breastfeeding

Undiagnosed menstrual bleeding Positive pregnancy test One week postpartum and breastfeeding Women with undiagnosed bleeding disorders should not take oral contraceptives (BCP). A woman who has been evaluated for irregular or heavy bleeding is sometimes prescribed BCP to manage bleeding. A woman who thinks she may be pregnant or is lactating should not take BCP.