SAUNDERS MATERNITY: Infections/Inflammation

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in 1 position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

1. "I should apply my antiembolism stockings after breakfast." Rationale:The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in 1 position and avoid placing pillows under the knees because of the risk for venous stasis in the lower extremities. The mother also should be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation. Test-Taking Strategy(ies):Note the strategic words, need for further education. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Focus on the goal of preventing venous stasis and congestion in the lower extremities. Also, knowledge regarding the application of antiembolism stockings will assist in directing you to the correct option.

A client who is a gravida 3, para 3 had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a 6 on a pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due to be administered now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used. 1.Prenatal vitamin 1 tablet orally daily 2.Docusate sodium 100 mg orally daily 3.Ampicillin sodium 1 g IV piggyback over 60 minutes 4.Ketorolac 30 mg by intravenous (IV) push over 3 minutes

4, 3, 2, 1 Rationale:The client is complaining of abdominal cramping, which is the priority and should be treated first; an IV route (ketorolac) is used because it will alleviate the pain rapidly. The risk of infection is greater than the need for a stool softener or a multivitamin; therefore, the IV antibiotic is administered next. The client who has not had her first bowel movement and is afraid to do so is the next priority; therefore, the docusate sodium would be administered next. The multivitamin requires daily administration and works over time to assist in replenishing the nutrients lost during blood loss associated with the surgery; this would be administered last. Test-Taking Strategy(ies):Note the strategic word, priority. Narrow the priority medications to the one that treats pain and the antibiotic for infection. Examine the routes and duration of administration of the medications listed. The ketorolac is administered intravenously over 3 minutes and has an onset of 30 minutes. The ampicillin sodium has to be administered over 60 minutes; therefore, the pain level could already have decreased by the time the antibiotic is administered if the ketorolac is given first. Next, think about the client's concern to determine that the docusate sodium is administered next.

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply. 1.Report a foul-smelling discharge. 2.Take a warm sitz baths 3 times a day. 3.Change the perineum pads 3 times a day. 4.Use warm water to rinse the perineum after elimination. 5.Wipe the perineum from front to back after voiding and defecation.

1, 2, 4, 5 Rationale:Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. Lochia should not have a foul smell; if it does, this should be reported immediately to the primary health care provider. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between. Warm water should be used to rinse the perineum after elimination. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Test-Taking Strategy(ies):Focus on the subject, measures to prevent an infection at the episiotomy site. Think about each option in terms of infection. Recall that the perineal pad should be changed after each elimination to assist you in eliminating option 3.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1. "You will need to bottle-feed your newborn." Rationale:Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV will most likely be advised not to breast-feed; however, PHCPs recommendations regarding breast-feeding are always followed. There is no physiological reason why the newborn needs to be fed by nasogastric tube. Test-Taking Strategy(ies):Use knowledge regarding the transmission of HIV. Eliminate options 3 and 4 first because these options are comparable or alike in that they both address breast-feeding. From the remaining options, select the correct option, knowing that it is unnecessary to feed the newborn by nasogastric tube.

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased diuresis and appetite 3. Maternal oral temperature of 100.2º F (37.9º C) 4. Fundus 2 fingerbreadths below umbilicus, midline and firm

1. Abdominal tenderness and chills Rationale:Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104º F (37.9º C). This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Increased diuresis and appetite, slight elevation in temperature, and firm fundus, midline below the umbilicus represent normal maternal physiological responses in the immediate postpartum period. Test-Taking Strategy(ies):Note the subject, signs and symptoms of endometritis, and focus on the normal and abnormal expected findings in the immediate postpartum period. Options 2, 3, and 4 represent the normal adaptation of reproductive organs (involution) and maternal physiological responses to decreased hormonal levels and fluid losses of labor. The correct option clearly indicates abnormal findings that require further evaluation of the client for endometritis.

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Ambulation 8 to 10 times daily 2. Administration of anticoagulants 3. Elevation of the affected extremity 4. Application of ice packs to the affected area

1. Ambulation 8 to 10 times daily Rationale:Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. There is usually no need for anticoagulants or anti-inflammatory agents unless the condition persists. Bed rest or limited activity may be prescribed depending on primary health care provider preference. Warm packs may be prescribed to be applied to the affected area to promote healing. Test-Taking Strategy(ies):Focus on the subject, superficial venous thrombosis. Recall that anticoagulants are not usually prescribed for this type of thrombophlebitis. From the remaining options, eliminate options 1 and 4, recalling that rest and warmth are prescribed to treat this complication.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1. Client pain level Rationale:The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume. Test-Taking Strategy(ies):Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory to eliminate option 3 because this is a psychosocial, not a physiological, need. To select from the remaining options, focus on the data in the question.

A postpartum client is diagnosed with a urinary tract infection. Which measures should the nurse instruct the client to take regarding treatment and the prevention of a future infection? 1. Urinate frequently throughout the day. 2. Take the prescribed medication until feeling better. 3. Minimize fluid intake especially during the evening hours. 4. Wipe the perineal area from back to front after urinating.

1. Urinate frequently throughout the day. Rationale:A client with a urinary tract infection should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. The client is also taught to wipe the perineal area from front to back after urinating or having a bowel movement. A woman with a urinary tract infection must be encouraged to take medication for the entire time it is prescribed; medication should not be stopped once the client is feeling better. Test-Taking Strategy(ies):Focus on the subject, measures to treat and prevent urinary tract infections. Specific knowledge of the treatment measures for urinary tract infection will assist to answer this question. Also, think about the pathophysiology associated with urinary tract infections and use general medication guidelines related to prescribed medication to answer correctly. Clients need to complete the course of prescribed medications.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1. The client has a history of intravenous drug use. 2. The client has a significant other who is heterosexual. 3. The client has a history of sexually transmitted infections. 4. The client has had one sexual partner for the past 10 years. 5. The client has a previous history of gestational diabetes mellitus.

1. The client has a history of intravenous drug use. 3. The client has a history of sexually transmitted infections. Rationale:HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV. Test-Taking Strategy(ies):Focus on the subject, risk factors for HIV. Recalling that exchange of blood and body fluids places the client at high risk for HIV infection will direct you to the correct options.

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk? 1.Presence of cats in the home 2.Number of sexual partners during pregnancy 3.Exposure to children with rashes or gastrointestinal symptoms 4.History of high fevers or unusual rashes during the first 6 weeks of pregnancy

1.Presence of cats in the home Rationale:Toxoplasmosis is a systemic (and usually asymptomatic) illness caused by a protozoan parasite. Approximately one third of all women in the United States have positive antibody titers for toxoplasmosis, thus confirming prior exposure. Humans acquire the infection by consuming inadequately cooked meat, eggs, or milk; by ingesting or inhaling the oocyst stage excreted in feline feces or contaminated soil; or by receiving contaminated blood products. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection in the developing embryo or fetus. The other options are questions unrelated to toxoplasmosis. Test-Taking Strategy(ies):Focus on the subject, risk factors for toxoplasmosis. Remember that toxoplasmosis can be contracted from contaminated kitty litter. Eliminate each of the incorrect options because they identify possible transmission routes for other known sexually transmitted or viral infections.

A postpartum client develops a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statements, if made by the mother, would indicate a need for further instruction? Select all that apply. 1. "I need to drink lots of fluids especially water every day." 2. "The prescribed medication needs to be taken until I feel better." 3. "Foods and fluids that will acidify the urine are best to consume." 4. "I need to try to hold my urine as long as I can and urinate 3 to 4 times a day." 5. "I may need to bring another urine sample to the lab after my treatment is complete."

2, 4 Rationale:The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder. Foods and fluids that acidify the urine should be encouraged. A follow-up urinalysis may be prescribed to ensure that the infection is resolved. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Recall that medication must be taken as prescribed for the full length of treatment even if the client is feeling better. Also, recall that holding the urine leads to stasis and worsens the condition.

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2. Ask the client about pain in the calf area. Rationale:Thrombophlebitis is a potential complication in the postpartum period. The client with thrombophlebitis may experience pain in the calf. The remaining options would not determine the presence of thrombophlebitis. Palpating pulses assesses circulation. The presence of a hematoma does not indicate thrombophlebitis. The nurse should not ask the client to ambulate if thrombophlebitis is suspected. Test-Taking Strategy(ies):Focus on the subject, thrombophlebitis. Think about the pathophysiology associated with thrombophlebitis and note the relationship between the pathophysiology and the correct option.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction? 1."I need to wear a supportive bra to relieve the discomfort." 2."I need to stop breast-feeding until this condition resolves." 3."I can use analgesics to assist in alleviating some of the discomfort." 4."I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2."I need to stop breast-feeding until this condition resolves." Rationale:Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Thinking about the pathophysiology associated with mastitis will assist you in eliminating the options containing "supportive bra," "analgesics," and "antibiotics" because these would all be appropriate statements by the client.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment, the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1."Mastitis usually involves both breasts." 2."Mastitis can occur at any time during breast-feeding." 3."Mastitis usually is caused by wearing a supportive bra." 4."Mastitis is most common for women who have breast-fed in the past."

2."Mastitis can occur at any time during breast-feeding." Rationale:Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. Mastitis is more common in mothers who are nursing for the first time and usually affects 1 breast only. A supportive bra will not cause mastitis; however, constriction of the breasts from a bra that is too tight may interfere with the emptying of all ducts and may lead to infection. Test-Taking Strategy(ies):Focus on the subject, the characteristics of mastitis. Specific knowledge about this condition is needed to answer the question. Remember that mastitis can occur at any time during breast-feeding.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1.Providing sitz baths 2.Encouraging fluid intake 3.Placing ice on the perineum 4.Monitoring hemoglobin and hematocrit levels

2.Encouraging fluid intake Rationale:Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage. Test-Taking Strategy(ies):Focus on the subject, measures to treat cystitis, and note the strategic word, priority. Remember that increased fluids are a priority intervention.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1.Therapeutic abortion is required. 2.Isoniazid plus rifampin will be required for 9 months. 3.She will have to stay at home until treatment is completed. 4.Medication will not be started until after delivery of the fetus.

2.Isoniazid plus rifampin will be required for 9 months. Rationale:More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required. Test-Taking Strategy(ies):Focus on the subject, therapeutic management for a client with tuberculosis. Recalling the pathophysiology associated with tuberculosis and its treatment will assist in eliminating options 1, 3, and 4.

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1.Offer only 1 breast at each feeding. 2.Massage distended areas as the infant nurses. 3.Express and discard milk from the affected breast at the first signs of mastitis. 4.Cleanse the nipples with a mild antibacterial soap before and after infant feedings.

2.Massage distended areas as the infant nurses. Rationale:Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. There is no need to discard breast milk. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently because infant sucking is thought to empty the breast more completely. Soap should not be used on the nipples because of the risk of drying or cracking. Test-Taking Strategy(ies):Focus on the subject, measures to prevent mastitis. Note the words breast-feed and important. Also, think about the pathophysiology associated with mastitis. Remember, massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis.

A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? 1.Costovertebral angle pain 2.Pain, itching, and vaginal discharge 3.Absence of any signs and symptoms 4.Proteinuria, hematuria, edema, and hypertension

2.Pain, itching, and vaginal discharge Rationale:Clinical manifestations of a vaginal Candida infection include pain; itching; and a thick, white vaginal discharge. Costovertebral angle pain, proteinuria, hematuria, edema, and hypertension are clinical manifestations that may be associated with a urinary tract infection. Test-Taking Strategy(ies):Focus on the subject, manifestations of a vaginal infection. Note the word vaginal in the question and in the correct option.

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction? 1."If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider." 2."Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis." 3."If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." 4."I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings."

3."If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." Rationale:The mother should not discontinue breast-feeding even if mastitis occurs. Mastitis, a breast infection, is best characterized by a sudden onset of flu-like symptoms; localized breast pain and tenderness; and a hot, reddened area on the breast that often resembles the shape of a pie wedge. Treatment usually includes antibiotics, but the mother should be instructed to feed the baby or pump frequently to adequately empty the affected breast. The remaining options are correct statements. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Reflect on the signs and symptoms of mastitis and the interventions and instructions necessary for treatment. Remember, the mother should not discontinue breast-feeding even if mastitis occurs.

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. 1."You should avoid all school-age children during pregnancy." 2."There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3."You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." 4."Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester."

3."You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." Rationale:Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information. Test-Taking Strategy(ies):Note the strategic word, best, and recall knowledge regarding the transmission of rubella virus to the fetus. Also, use of therapeutic communication techniques will direct you to the correct option. The correct option addresses the client's concerns.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1.Pump both breasts and discard the milk. 2.Bottle-feed the infant on a temporary basis. 3.Breast-feed from the left breast and gently pump the right breast. 4.Stop breast-feeding from both breasts until this condition resolves.

3.Breast-feed from the left breast and gently pump the right breast. Rationale:In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). The remaining options are incorrect instructions. Test-Taking Strategy(ies):Focus on the subject, instructions for the mother with mastitis. Eliminate discarding of breast milk, bottle-feeding the infant, and discontinuing breast-feeding because these options are comparable or alike and indicate that the mother should discontinue breast-feeding.

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? 1.Provide the client with instructions on how to push. 2.Prepare the labor room and the client for an imminent delivery. 3.Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4.Call the PHCP to the labor and delivery unit to perform a delivery.

3.Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). Rationale:The client evidences progression toward delivery because the cervix is dilated 6 cm and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, her neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that IAP be administered during labor. Providing the client with instructions on pushing is not appropriate at a time when she does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore, the PHCP is not required for delivery at this time. Test-Taking Strategy(ies):Note the strategic word, first. Focus on the data in the question. Note that options 1, 2, and 4 are comparable or alike and indicate that the client is close to delivery, which she is not. Administering IAP because of the client's GBS result should be a priority for the nurse before delivery.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1.Paleness of the calf area 2.Coolness of the calf area 3.Enlarged, hardened veins 4.Palpable dorsalis pedis pulses

3.Enlarged, hardened veins Rationale:Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding. Test-Taking Strategy(ies):Eliminate option 4 first because this is a normal and expected finding. Next, eliminate options 1 and 2 because they are comparable or alike.

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement should the nurse make to the client? 1.Visitors are not allowed to hold the baby. 2.There is no danger of the newborn contracting the disease. 3.Hands should be washed thoroughly before holding the infant. 4.The newborn infant will not be allowed in the mother's room at all.

3.Hands should be washed thoroughly before holding the infant. Rationale:Transmission of infectious diseases can occur through contaminated items such as the hands and bed linens of clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is 1 of the most effective methods of preventing the transmission of infectious diseases. The newborn infant is allowed in the mother's room and visitors are allowed to hold the newborn infant as long as hand washing and other protective measures are instituted. Test-Taking Strategy(ies):Focus on the subject, preventing the spread of infection. Eliminate options 1, 2, and 4 because of the closed-ended words "not," "no," and "not . . . at all."

A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? 1. The woman has the herpes simplex virus (HSV). 2. The woman has contracted an airborne viral disease. 3. The neonate will definitely develop this disease after birth. 4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.

4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test. Rationale:Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA. HIV and herpes simplex virus are different types of infections. HIV infection occurs primarily through the exchange of body fluids, not via airborne disease. A neonate born to an HIV-positive mother is at risk for developing the virus, but it is not an absolute. Test-Taking Strategy(ies):First, eliminate option 3 because it includes the closed-ended word "definitely." Next, eliminate option 2, knowing that HIV infection occurs primarily through the exchange of body fluids. Finally, eliminate option 1, which indicates that the woman has HSV, which is not the same infection as HIV.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1."I need to urinate frequently throughout the day." 2."The prescribed medication must be taken until it is finished." 3."My fluid intake should be increased to at least 3000 mL daily." 4."Foods and fluids that will increase urine alkalinity should be consumed."

4."Foods and fluids that will increase urine alkalinity should be consumed." Rationale:A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Recall that foods and fluids that acidify the urine should be consumed, rather than foods and fluids that cause urine alkalinity.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction? 1."I need to take the antibiotics as prescribed." 2."I need to take warm sitz baths to promote healing." 3."I need to apply warm compresses to provide comfort." 4."I need to isolate the infant for 48 hours after beginning the antibiotics."

4."I need to isolate the infant for 48 hours after beginning the antibiotics." Rationale:The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand-washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and sitz baths or warm compresses may be used to provide comfort in the area. There is no need to isolate the infant. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select the option that is an incorrect statement. Eliminate options 2 and 3 first because they are comparable or alike. Knowing that the infant does not need to be isolated from the mother will assist in directing you to the correct option from those remaining.

The nurse is providing instructions regarding the treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? 1."I should avoid straining during bowel movements." 2."I can gently replace the hemorrhoids into the rectum." 3."I can apply ice packs to the hemorrhoids to reduce the swelling." 4."I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

4."I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." Rationale:Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the discomfort from hemorrhoids. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling the principles regarding heat and cold will assist in directing you to the correct option.

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? 1."I can douche anytime I want." 2."I can wear my tight-fitting jeans." 3."I should avoid the use of condoms." 4."I should wear underwear with a cotton panel liner."

4."I should wear underwear with a cotton panel liner." Rationale:Wearing items with a cotton panel liner allows for air movement in and around the genital area. Douching is to be avoided. Wearing tight clothing can irritate the genital area and does not allow for air circulation. Condoms should be used to minimize the spread of genital tract infections. Test-Taking Strategy(ies):Focus on the subject, an understanding of measures to prevent genital tract infections. Think about what actions will promote infection to direct you to the option of wearing undergarments with a cotton panel liner. The remaining options are all incorrect statements regarding client self-care.

The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? 1."I do not need to abstain from sexual intercourse." 2."I need to use vaginal creams after I douche every day." 3."I need to douche and perform a sitz bath 3 times a day." 4."It may be necessary to have a cesarean section for delivery."

4."It may be necessary to have a cesarean section for delivery." Rationale:If a woman has an active lesion, either recurrent or primary at the time of labor, delivery should be by cesarean section. Women are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the woman should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area should be kept clean and dry to promote healing. Test-Taking Strategy(ies):Focus on the subject, an understanding of the instructions related to treatment modalities for herpes genitalis. Options 2 and 3 can be eliminated first because they are comparable or alike. Next, eliminate option 1 because of the words do not.

The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the primary health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? 1."This is necessary to relieve your anxiety." 2."This is necessary to eliminate the need for further uncomfortable screenings." 3."This is necessary to minimize the financial cost of caring for an HIV-positive client." 4."This is necessary to assist in identifying potential infections that may need to be treated."

4."This is necessary to assist in identifying potential infections that may need to be treated." Rationale:The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include, for example, Candida infections, genital herpes, and anogenital condyloma. Early reporting of signs and symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being. Test-Taking Strategy(ies):Focus on the subject, signs to report to the primary health care provider, keeping in mind that the HIV-positive client is immunocompromised. Also use Maslow's Hierarchy of Needs theory to direct you to the correct option. The correct option is the only one that addresses physiological integrity.

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman? 1."You should avoid all school-age children during pregnancy." 2."There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3."Be sure to tell the primary health care provider on your next prenatal visit, but there is little risk in the second trimester." 4."You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed."

4."You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed." Rationale:Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks associated with maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies. Rubella titer determination is a standard antenatal test for childbearing women during their initial screening and entry into the health care delivery system. The correct option helps to clarify maternal concerns with accurate information based on the acquisition of rubella infection and potential fetal side effects. Test-Taking Strategy(ies):Focus on the strategic words, most appropriate. Use the knowledge regarding the transmission of rubella virus to the fetus. Also, understanding of therapeutic communication techniques will direct you to the correct option. The correct option addresses the client's concerns.

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? 1."Most children do not receive the vaccine until they are 5 years of age." 2."You are still susceptible to rubella, so your toddler should receive the vaccine." 3."It is not advised for children of pregnant women to be vaccinated during their mother's pregnancy." 4."Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."

4."Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." Rationale:All pregnant women should be screened for prior rubella exposure during pregnancy. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to rubella. All children of pregnant women should receive their immunizations according to schedule. In addition, no definitive evidence suggests that the rubella vaccine virus is transmitted from client to client. Test-Taking Strategy(ies):Note the strategic word, best, and focus on the subject, rubella immunization for a child of a pregnant client. Recalling that a positive titer indicates immunity will direct you to the correct option.

The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1.A primigravida with a normal spontaneous vaginal delivery 2.A gravida 2 who delivered vaginally following an 18-hour labor 3.A client experiencing an elective cesarean delivery at 38 weeks' gestation 4.An adolescent experiencing an emergency cesarean delivery for fetal distress

4.An adolescent experiencing an emergency cesarean delivery for fetal distress Rationale:Endometritis is an acute infection of the uterine mucous lining immediately after delivery. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options provided do not describe the client most at risk for developing endometritis following delivery. Test-Taking Strategy(ies):Note the strategic word, most, and focus on the subject, the client most at risk for postdelivery endometritis. Use knowledge of the cause of endometritis to assist you in answering the question. Noting the words fetal distress in the correct choice will assist in directing you to option 4.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1.Document the findings. 2.Notify the obstetrician. 3.Retake the temperature in 15 minutes. 4.Increase hydration by encouraging oral fluids.

4.Increase hydration by encouraging oral fluids. Rationale:The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the obstetrician is not necessary. Test-Taking Strategy(ies):Note the strategic word, priority, and use knowledge regarding the physiological findings in the immediate postpartum period to answer this question. Recalling that a temperature elevation often is related to the dehydrating effects of labor will direct you to the correct option. Also, increasing hydration relates to a physiological client need.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1.The client with mild afterpains 2.The client with a pulse rate of 60 beats per minute 3.The client with colostrum discharge from both breasts 4.The client with lochia that is red and has a foul-smelling odor

4.The client with lochia that is red and has a foul-smelling odor Rationale:Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client. Test-Taking Strategy(ies):Note the strategic words, need for follow-up. These words indicate a negative event query and the need to select the abnormal assessment finding. Note the words foul-smelling in the correct option.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1.The mother requests that the window be closed before feeding. 2.The mother holds the newborn properly during feeding and burping. 3.The mother tests the temperature of the formula before initiating feeding. 4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. Rationale:Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, disease transmission to the newborn. This focus will direct you to the correct option.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1.Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL/day. 4.Continue to breast-feed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Rationale:Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess. Test-Taking Strategy(ies):Focus on the subject, treatment measures for mastitis. Think about the pathophysiology associated with mastitis to answer correctly. Recalling that supportive measures include rest, moist heat or ice packs, antibiotics, analgesics, increased fluid intake, breast support, and decompression of the breasts will assist in answering the question.

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? Select all that apply. 1.A mother who had 10 vaginal exams during labor 2.A mother with a history of previous puerperal infections 3.A mother who gave birth vaginally to a 3200-gram infant 4.A mother who experienced prolonged rupture of the membranes 5.A mother who experienced the expected outcome with delivery of the placenta

1, 2, 4 Rationale:Risk factors associated with puerperal infection include a history of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, and retained placental fragments. Test-Taking Strategy(ies):Note the strategic words, most likely and note the subject, the risk for puerperal infection. Think about the pathophysiology associated with the development of infection to answer correctly.

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? 1. Maternal infection 2. Gestational hypertension 3. Gestational diabetes mellitus 4. Consumption of recent high-sugar snack

1. Maternal infection Rationale:The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to approximately 110 to 160 beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes, and consuming a high-sugar diet may affect the fetal heart rate but are not the most likely causes. Test-Taking Strategy(ies):Focus on the subject, a tachycardic fetal heart rate of 180 beats/minute. Note the strategic words, most likely, and remember the effects of infection on the fetus to direct you to the correct option.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at most risk for development of postpartum thromboembolic disorders? 1.A 39-year-old woman who reports that she smokes 2.A 24-year-old woman with a thin frame who is a vegetarian 3.A 30-year-old woman in her fourth pregnancy who is normal weight 4.A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have not caused any adverse effects

1.A 39-year-old woman who reports that she smokes Rationale:Certain factors create a risk for the development of thromboembolic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than 3 pregnancies, and women who have had a cesarean birth. Test-Taking Strategy(ies):Note the strategic word, most, and focus on the subject, risk factors for thromboembolic disorders postpartum. Knowing that a woman older than 35 years of age is at risk will assist in selecting option 1. Also, noting that this client smokes will assist in answering correctly.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1.Breast-feeding needs to be stopped for 3 months. 2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs. 6.The area of the injection needs to be covered with a sterile gauze for 1 week.

2, 3, 4, 5 Rationale:Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization or as specified by the obstetrician because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze. Test-Taking Strategy(ies):Focus on the subject, client instructions regarding the rubella vaccine. Recalling that the rubella vaccine is a live virus vaccine will assist in selecting options 2 and 5. Next, recalling the route of administration and the contraindications associated with its use will assist in selecting options 3 and 4.

A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate? 1. "Breast-feeding can start 6 months after delivery." 2. "Breast-feeding is allowed after the baby has been vaccinated with immune globulin." 3. "Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby." 4. "Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery."

2. "Breast-feeding is allowed after the baby has been vaccinated with immune globulin." Rationale:Although HBV is transmitted in breast milk, after scheduled newborn vaccines and immune globulin have been administered to the newborn, the woman may breast-feed without risk to the newborn. The remaining options are incorrect responses. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Specific knowledge of the pathophysiology associated with HBV and its effects on the fetus and newborn is required to answer this question. Knowing that the woman will be able to continue to breast-feed after the infant has received immune globulin will assist in directing you to the correct option. In addition, use therapeutic communication techniques to assist in eliminating the incorrect options.

A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction? 1. "I should cook meat thoroughly." 2. "I should drink unpasteurized milk only." 3. "I should avoid contact with materials that are possibly contaminated with cat feces." 4. "I should avoid touching mucous membranes of the mouth or eyes while handling raw meat."

2. "I should drink unpasteurized milk only." Rationale:All pregnant women should be advised to follow certain procedures to prevent the development of toxoplasmosis. All meats should be cooked thoroughly. Pregnant clients should avoid uncooked eggs and unpasteurized milk. All fruits and vegetables should be washed before consumption. Contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sand boxes, or garden soil should be avoided. Last, the pregnant client should avoid touching mucous membranes of the mouth or eyes while handling raw meat, thoroughly wash all kitchen surfaces that come in contact with uncooked meat, and wash the hands thoroughly after handling raw meat. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. This phrasing indicates a negative event query and asks you to select an incorrect client statement. Think about the methods of transmission of toxoplasmosis. Also, note the closed-ended word "only" in the correct option.

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period? 1. A 35-year-old client who reports that she smokes 2. A 26-year-old client with a family history of thrombophlebitis 3. A 37-year-old client in her fourth pregnancy who is overweight 4. A 22-year-old client in her first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

2. A 26-year-old client with a family history of thrombophlebitis Rationale:Certain factors create a risk for the development of thrombophlebitis. These factors include smoking, varicose veins, obesity, a history of thrombophlebitis, women who are older than 35 years or have had more than 3 pregnancies, and women who have had a cesarean birth. The client described in the correct option is least likely to be at risk for the development of a thromboembolic disorder because this client has a family history rather than a personal history of thrombophlebitis. Test-Taking Strategy(ies):Focus on the subject, the client least likely to be at risk for the development of thrombophlebitis. Note the words, least likely. Use specific knowledge of the pathophysiology and risks associated with thrombophlebitis to assist you in answering the question. Noting the words family history in the correct choice will direct you to this option.

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? 1. Immunization with rubella 2. Retesting rubella titer during pregnancy 3. Antibiotics to be taken throughout the pregnancy 4. Counseling the mother regarding therapeutic abortion

2. Retesting rubella titer during pregnancy Rationale:A rubella titer is performed to determine immunity to rubella. If the client's titer is less than 1:8, the mother is not immune. A retest during pregnancy is prescribed, and the mother is immunized postpartum if she is not immune. Antibiotics are not prescribed. Counseling the client regarding therapeutic abortion is an inaccurate option. Test-Taking Strategy(ies):Focus on the subject, that the client is not immune to rubella. Specific knowledge regarding immunity and the rubella titer during pregnancy will direct you to the correct option. Noting that the client is pregnant will assist in directing you to the correct option.

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1. Perform an abdominal scrub on the client. 2. Prepare the delivery room for a vaginal delivery. 3. Explain to the client why a cesarean delivery is necessary. 4. Call the primary health care provider to obtain a prescription for an antiviral medication.

3. Explain to the client why a cesarean delivery is necessary. Rationale:Because neonatal infection of HSV is life-threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal scrub will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms, not to eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV. Test-Taking Strategy(ies):Note the strategic word, initial. Eliminate options 2 and 4, which indicate to prepare for vaginal delivery and to obtain a prescription for antiviral medications, because they are not the recommended options for a client with HSV lesions who is in active labor. From the remaining options, remember that the action in option 3 must occur before any othe

The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? 1. Encourage early ambulation. 2. Discuss the resumption of home care and other activities with the client. 3. Review hand-washing techniques and pericare procedures with the client. 4. Instruct the client in proper positioning of the newborn to facilitate breast-feeding.

3. Review hand-washing techniques and pericare procedures with the client. Rationale:Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand-washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication. Test-Taking Strategy(ies):Options 2 and 4 can be eliminated first because they are comparable or alike. Regarding the remaining options, use medical terminology skills relating to the word endometritis to direct you to the correct option. Remember that the suffix -itis indicates inflammation or infection.

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 instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Rationale:Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and the need to select the option that identifies the incorrect client statement. Recalling that the use of soap is drying to the skin and could cause cracking and provide an entry point for organisms will direct you easily to the correct option.

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? 1. "You will be isolated from your newborn infant after delivery." 2. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3. "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed." Rationale:With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery. Test-Taking Strategy(ies):Focus on the subject, indications for delivery for the pregnant client with genital herpes. Knowledge of the transmission of genital herpes to a newborn infant will assist you to answer this question. Remember that in clients with active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks.

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed.

4. Encourage the client to take pain medication as prescribed. Rationale:Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. If the client's pain is relieved, she will be more likely to participate in newborn care. Asking family members to care for the newborn will not facilitate client participation in newborn care. Test-Taking Strategy(ies):Focus on the subject, facilitating participation in newborn care. This will assist in eliminating the family caring for the newborn. Use knowledge of the therapeutic management of endometritis to select from the remaining options. Remember that if the client's pain is relieved, she will be more likely to participate in newborn care.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? 1. Anxiety 2. Hot flashes 3. Low self-esteem 4. Postpartum infection

4. Postpartum infection Rationale:Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hot flashes. Anxiety and low self-esteem are unrelated to physiological integrity. Test-Taking Strategy(ies):Use Maslow's Hierarchy of Needs theory. Eliminate options 1 and 3 first because they are not physiological needs. Regarding the remaining options, focusing on the subject, anemia in a client in labor, will direct you to the correct option.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1.Bed rest as a necessary preventive measure may be prescribed. 2.Administration of subcutaneous heparin postdelivery as prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.

2, 3, 5 Rationale:The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots. Test-Taking Strategy(ies):Note the subject, planning care for the pregnant client who is obese. If you can recall the general complications associated with obesity, this will help you choose the correct options. Recall that preventive measures need to be taken to prevent blood clots and infection in clients at higher risk for these complications.

A pregnant client is diagnosed with tuberculosis. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis? 1.Medication is not needed until after delivery. 2.Tuberculosis is nothing to be concerned about. 3.Tuberculosis cannot be transferred to the fetus. 4.The newborn will be tested at birth and may be started on preventive therapy.

4.The newborn will be tested at birth and may be started on preventive therapy. Rationale:More than 1 medication may be used to prevent the growth of resistant organisms in the pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for a total of 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing on the infant should be repeated at 3 months, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid should be given. Therefore, options 1, 2, and 3 are incorrect. Test-Taking Strategy(ies):Focus on the subject, therapeutic management of tuberculosis. Recall the risks associated with tuberculosis and that this communicable disease is treated with medication to direct you to option 4.