HESI COMPASS MODULE 1 PRACTICE

A nurse is planning to determine the presentation and position of the fetus, using the Leopold maneuvers. Prioritize and number the nursing actions in the order in which they would be performed. (The number 1 would indicate the first action and the number 6 represents the last action.) From smallest to largest, what are the different classes of structures that make up the human body? ____. Palpate the sides of the uterus to determine the location of the fetal back. ____. Palpate the uterine fundus to determine the fetal part felt. ____. Wash hands and don gloves. ____. Palpate the suprapubic area to determine whether the presenting part is engaged. ____. Ask the woman to empty her bladder. ____. Explain the procedure to the woman.

1. Explain the procedure to the woman. 2. Ask the woman to empty her bladder. 3. Wash hands and don gloves. 4. Palpate the uterine fundus to determine the fetal part felt. 5. Palpate the sides of the uterus to determine the location of the fetal back. 6. Palpate the suprapubic area to determine whether the presenting part is engaged.

Which action should the nurse implement first to treat the dehydration? A. Administering oral Pedialyte B. Instituting NPO (nothing-by-mouth) status C. Encouraging Mrs. Valenti to drink sips of water D. Starting an intravenous (IV) line and administer IV fluids

A Rationale: Oral hydration is the first approach to the treatment of dehydration if the client is able to ingest fluids. Sport drinks, though high in sugar, are often recommended over tap water because they are easily absorbed by the stomach, are generally palatable to clients, and will more quickly correct the dehydration. Pedialyte and other commercial fluid and electrolyte solutions are also available. The administration of IV fluids is a last-resort approach. There is no reason to maintain Mrs. Valenti on NPO status; in fact, this could worsen the dehydration.

A female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client? A. That it offers protection against sexually transmitted infections (STIs) B. That it is 100% safe in preventing pregnancy C. That it does not have to be discarded after use and can be used several times before a new one must be obtained D. It can be used along with a male condom

A Rationale: A female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. The condom, which is prelubricated, is available without a prescription. It cannot be combined with a male condom and should be used just once, then discarded. Like the male condom, the female condom provides protection against STIs. The pregnancy failure rate with typical use is approximately 21%.

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? A. "I need to wear additional antiperspirant and deodorant in warm weather." B. "I need to wear a hat with a wide brim when I go outdoors." C. "I should drink extra fluids during the summer." D. "I should wear cool, light clothing in warm weather."

A Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is decreased. However, older adults are at a greater risk of heatstroke as a result of a compromised cooling mechanism; they should therefore avoid heat exposure over long periods and in areas of high humidity. The older adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing when outdoors. It is also important that the older adult maintain adequate hydration, particularly during the summer and in hot climates.

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? A. Back of the fetus B. Brachial area of one extremity of the fetus C. Chest of the fetus D. Carotid artery in the neck of the fetus

A Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and to determine the location of the fetal back. The fetal heart rate is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Because of the position of the fetus in the maternal abdomen (fetal position), auscultation of the FHR over the chest, carotid artery, or brachial area is not possible.

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? A. Use water and a cotton swab and rub the teeth B. Use a small amount of toothpaste and a soft-bristle toothbrush C. Use diluted fluoride and rub the teeth with a soft washcloth D. Dip the infant's pacifier in maple syrup so that the infant will suck

A Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay.

Penny's labor continues, and she is now at 9 cm of dilation. During contractions, the fetal heart monitor shows the patterns depicted on the graph. What does the nurse determine? A. No action is required B. The oxytocin infusion must be stopped C. Penny should be moved into a side-lying position D. Oxygen, at a rate of 8-10 L/min via face mask, needs to be administered

A Rationale: Early deceleration of the fetal heart rate (FHR) is an obvious gradual decrease and then return to baseline that is associated with uterine contractions. Early decelerations are considered benign, and nursing interventions are not required. Moving the mother into a side-lying position, administering oxygen, and stopping the oxytocin infusion are interventions that would be needed for late or variable decelerations of the FHR, which may indicate fetal distress.

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz (3.2 kg) about car safety. What should the nurse tell the mother? A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat B. That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags C. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car D. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant

A Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb (9.1 kg) and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car.

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take? A. Tell the mother that the infant's weight is increasing as expected B. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes C. Tell the mother to decrease the daily number of feedings because the weight gain is excessive D. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate

A Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz (2.9 kg), at birth, a weight of 13 lb (5.9 kg) at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age.

A nurse monitoring lochial flow in a woman who delivered 2 hours earlier notes that the client's perineal pad shows drainage measuring less than 1 inch in a 1-hour period. How should the nurse report the lochial flow? A. Scant B. Light C. Heavy D. Excessive

A Rationale: Lochia is the discharge from the uterus in the postpartum period, consists of blood from the vessels of the placental site and debris from the decidua (thick layer of modified mucous membrane that lines the uterus during pregnancy and is shed with afterbirth). The following guide may be used to determine the amount of flow: scant, less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light, less than 10 cm (4 inches) on pad in 1 hour; moderate, less than 15 cm (6 inches) on pad in 1 hour; heavy, saturation of pad in 1 hour; and excessive, saturation of pad in 15 minutes.

Maureen and Robert decide to have James Nicholas circumcised before he is discharged from the hospital. The nurse conducts teaching for home care of the circumcised newborn. Which statement by Maureen indicates a need for further instruction? A. "I'll clean the penis with a baby wipe during each diaper change." B. "I'll check the circumcision site for bleeding during each diaper change." C. "I'll apply petroleum jelly to the penis during each diaper change until it heals." D. "If his penis turns red, swells, or has a discharge, I'll call the pediatrician right away."

A Rationale: Many newborn infants are discharged soon after circumcision, and thorough client teaching is important. Parents should be taught to check carefully for bleeding, to cleanse the site with warm water until the circumcision is healed (5 to 6 days), and to apply petroleum jelly during each diaper change until the site is healed. Redness, swelling, or discharge indicates infection, and the primary health care provider should be notified immediately if any of these findings are noted. Commercial baby wipes should not be used because they contain alcohol, which may delay healing and cause discomfort for the newborn.

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. Which question should the nurse ask to identify risk factors associated with the use of an oral contraceptive? A. "Do you smoke cigarettes?" B. "Are you dieting?" C. "Do you engage in strenuous exercise such as jogging?" D. "Do you normally have menstrual cramps with your periods?"

A Rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolitic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives.

After a year, Marilyn calls the nurse to report that she may be pregnant. She says, "I missed 2 days of pills, so we've been using the rhythm method. Do I still take today's pill?" Which responses by the nurse are appropriate? Select all that apply. A. "Can you stop by the office this afternoon for a pregnancy test?" B. "Keep taking the birth control until your pregnancy is confirmed." C. "The rhythm method is quite accurate. You probably are not pregnant." D. "Wait a week, and if you still think you're pregnant stop the birth control pill." E. "Do not take the birth control until you are tested in the office for pregnancy."

A Rationale: Pregnancy, or possible pregnancy, is a contraindication to the use of oral contraceptives. The client should be told to stop taking the contraceptive until pregnancy is confirmed or ruled out. The rhythm method, though commonly used, is not always effective, because ovulation is often irregular. The nurse cannot determine whether the client is pregnant with just a telephone conversation. A pregnancy test should be performed as soon as possible.

The next day, the newborn's blood type comes back as A-positive. Annie is type B-negative. The obstetrician prescribes an intramuscular dose of Rho(D) immunoglobulin (RhoGAM) for Annie. The nurse explains the purpose of the RhoGAM, and prepares the injection. Which statement by Annie reflects a need for further education? A. "My baby will need a dose of this medication, too." B. "My husband doesn't need to have a dose of this medication." C. "This shot will prevent a reaction in my body from the blood of my baby." D. "This shot will make it safer for my future babies if they have a positive blood type."

A Rationale: Rho(D) immunoglobulin (RhoGAM) is given within 72 hours of delivery to prevent antibody sensitization in a Rh-negative woman who has given birth to a Rh-positive infant, in whom fetomaternal transfusion may have occurred. The immune globulin promotes the destruction of any fetal Rh-positive cells that may have entered the mother's bloodstream before her body has had a chance to form antibodies against them. As a result, future pregnancies with Rh-positive infants will not be at risk for hemolysis. Only the mother receives the injection.

A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? A. Document the findings B. Notify the primary health care provider immediately C. Obtain a prescription for a muscle relaxant D. Ask the primary health care provider about referring the client to a neurological specialist

A Rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying yes), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the primary health care provider immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect.

A nurse notes documentation in the medical record that a woman in labor is at +1 station. Based on this finding, what does the nurse determine is the presenting part of the fetus? A. 1 cm below the ischial spines B. 1 cm above the ischial spines\ C. At the level of the ischial spines D. Above the level of the ischial spines

A Rationale: Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. Station is expressed in centimeters above or below the spines. When the presenting part is 1 cm below the ischial spines, the station is noted as +1. When the presenting part is 1 cm above the ischial spines, the station is noted as -1. When the presenting part is at the level of the ischial spines, the station is noted as zero.

A client discussing family planning methods with the nurse tells the nurse that she uses the calendar method because her menstrual periods are regular. Which information about the reliability of this method should the nurse provide to the client? A. It is unreliable B. It is extremely reliable if menstrual periods are regular. C. If it has prevented pregnancy so far, it is a reliable method. D. It is very reliable if the basal body temperature method is also used.

A Rationale: The calendar method is based on the fact that ovulation occurs approximately 14 days before the onset of menses. It is unreliable because many factors, such as illness or stress, can affect the time of ovulation. In the basal body temperature method, the woman charts her temperature each morning before getting out of bed. The basal body temperature may decrease slightly before ovulation and then increase slightly with ovulation. This method, which is not reliable because errors are frequent, is often used along with other methods. Therefore the other options are incorrect.

A mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? A. Soon after the first primary tooth erupts, usually around 1 year of age B. At age 3 C. Twelve months after the first primary tooth erupts D. Just before beginning kindergarten

A Rationale: The child should see the dentist soon after the first primary tooth erupts at around 1 year of age. Therefore the remaining options are incorrect. Parents should be aware of the dental guidelines for children and should not delay necessary dental care.

A nurse is preparing to apply erythromycin ophthalmic ointment to a newborn's eyes. Which action should the nurse plan to take? A. Cleansing the infant's eyes before applying the ointment B. Applying the ointment to the upper conjunctival sac of each eye C. Rinsing the excess ointment from the eye using normal saline solution D. Applying the ointment from the outer canthus to the inner canthus of the eye

A Rationale: The infant's eyes are cleansed before the administration of eye ointment. The ointment is placed in the lower conjunctival sac of each eye and deposited from the inner canthus to the outer canthus. The ointment is not rinsed from the eye, although it may be wiped from the outer eye area after 1 minute.

A nurse performing an initial assessment of a newborn who is awake and alert counts the infant's apical heart rate and obtains a rate of 130 beats/min. Based on this finding, which action should the nurse take? A. Documenting the finding B. Contacting the pediatrician C. Reassessing the heart rate in 5 minutes D. Stimulating the infant and reassessing the heart rate

A Rationale: The normal heart rate of a newborn is 100 to 160 beats/min. Therefore the nurse would document the finding. The other options are incorrect and unnecessary.

A nurse assessing a newborn's reflexes tests the Babinski (plantar) reflex. The nurse notes that when the reflex is elicited, the infant's toes hyperextend and the big toe dorsiflexes. How should the nurse document this finding? A. Positive B. Negative C. Unresponsive D. Depressed

A Rationale: To elicit the Babinski reflex, the nurse begins at the heel of the foot and strokes upward along the lateral aspect of the sole of the foot, then moves the finger across the ball of the foot. In the characteristic response, all toes hyperextend and the big toe dorsiflexes. This is recorded as a positive sign. Although the response depends on general muscle tone and condition of the infant, an absence of response requires neurological evaluation. Therefore the other options are incorrect.

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? A. Use of a latex condom can prevent transmission of STIs B. Use of a latex condom is a good method for preventing pregnancy C. A spermicide needs to be used along with a condom to prevent transmission of STIs D. The only way to prevent transmission of STIs is abstinence

A Rationale: Use of a condom during intercourse can prevent transmission of STIs. Abstinence is not the only way to prevent transmission of an STI. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs.

The nurse is assessing Mrs. Valenti's nutritional status. Which statements by Mrs. Valenti indicate a risk for malnutrition? Select all that apply. A. "Sometimes I have to make myself eat." B. "My weight stays about the same each week." C. "Food just doesn't taste the same as it used to." D. "I have to wear my dentures to chew my food." E. "Sometimes I have trouble swallowing my food."

A, C, E Rationale: Several factors including dysphagia, decreased enjoyment of food because of a diminished sense of taste, and a lower motivation to eat may increase the risk of malnutrition in an older adult. Many older adults require dentures to eat, but this is only a problem if they are ill fitting. A stable weight and consumption of several servings of fruits and vegetables every day are signs/symptoms of good nutrition.

After 2 days Mrs. Valenti is feeling better, and the discharge planner begins arranging for her to be sent back to the residential home. The nurse gives report to the nurse at the home, and Mrs. Valenti arrives there late in the afternoon. Which measures should the nurse at the residential home implement to prevent recurrence of dehydration? Select all that apply. A. Assess urine output B. Offering fluids with meals only C. Offering fluids other than water, such as coffee and iced tea D. Monitoring her pulse and respiratory rates, and blood pressure E. Find out what fluids she prefers besides water and offer those

A, D, E Rationale: Measures to help prevent dehydration in older adults include monitoring pulse rate and respiration for increases and the blood pressure for a decrease, all of which may indicate dehydration. In addition, urine output should be monitored, because decreased urine output may indicate dehydration. Fluids should be offered every hour, including with the evening snack, and the nurse should find out what fluids are preferred and offer those, with the exception of drinks containing caffeine (e.g., coffee and iced tea), which acts as a diuretic.

A non-stress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? A. Fetal well-being has been established. B. A contraction stress test will be scheduled. C. Placental function and oxygenation are adequate. D. The results are inadequate and the non-stress test must be repeated.

B Rationale: A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if non stress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? A. Experience frustration to allow an infant to cry for a while before meeting his or her needs B. Rely on the fact that their needs will be met C. Tolerate a great deal of frustration and discomfort to develop a healthy personality D. Ignore needs for short periods to develop a healthy personality

B Rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect.

A nurse assists an obstetrician in performing an amniotomy on a woman admitted to the labor unit. Which action should the nurse take immediately after the procedure? A. Helping the woman walk B. Checking the fetal heart rate C. Assisting the woman in bathing D. Checking the woman's temperature

B Rationale: Amniotomy is the artificial rupture of membranes that is performed by the primary health care provider to stimulate labor. The primary risk associated with amniotomy is that the umbilical cord will slip down in the gush of fluid and become compressed between the fetal presenting part and the woman's pelvis, obstructing blood flow to and from the placenta and reducing gas exchange. Therefore the nurse's action immediately after the procedure would be to check the fetal heart rate. Although the nurse would monitor the woman's temperature and help the woman bathe, these are not immediately necessary actions. The woman would not be allowed to walk unless this has specifically been prescribed.

A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? A. Week 1 B. Week 5 C. Week 8 D. Week 9

B Rationale: By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore, the other options are incorrect.

A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? A. She must come to the clinic to be checked. B. This is an expected occurrence during pregnancy. C. This is frequently the first sign of a breast infection. D. She should notify the nurse-midwife of this finding.

B Rationale: Colostrum, the creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples as early as 16 weeks' gestation. This is an expected occurrence during pregnancy. It is not necessary for the client to notify the nurse-midwife or to report to the clinic to be checked. It is not a sign/symptom of infection.

A nurse monitoring the fetal heart rate (FHR) pattern of a woman in the first stage of labor whose cervix is dilated 6 cm notes the presence of early decelerations. Based on this finding, what action should the nurse take? A. Contacting the nurse-midwife B. Continuing to monitor the FHR pattern C. Administering oxygen at 10 L by face mask D. Preparing the woman for immediate delivery

B Rationale: Early deceleration of FHR is a visually apparent gradual decrease and return to baseline FHR that occurs in response to fetal head compression during a contraction. It is a normal and benign finding, and therefore no intervention is necessary.

A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? A. 4 days B. 10 days C. 14 days D. 21 days

B Rationale: Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother? A. Hepatitis B is a concern with body piercing B. Body piercing is generally harmless as long as it is performed under sterile conditions C. Infection always occurs when body piercing is done D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

B Rationale: Generally body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some of the complications that may occur are bleeding, infection, keloid formation, and the development of allergies to metal. The area needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not associated with body piercing; however, they are a possibility with tattooing.

A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? A. The client is definitely pregnant. B. The nurse-midwife noted softening of the cervix. C. The client exhibits a presumptive sign of pregnancy. D. The nurse-midwife noted a violet coloration of the cervix.

B Rationale: In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.

A mother changing her newborn daughter's diaper notes the presence of a small amount of blood on the infant's labia. The mother is concerned and tells the nurse that the infant is bleeding from the vaginal area. After assessing the infant, what response does the nurse provide to the mother? A. The pediatrician will need to check the infant B. A small amount of vaginal bleeding is normal C. The bleeding is nothing to be concerned about D. The bleeding is probably a result of trauma from the birth process

B Rationale: In the full-term female infant, edema of the labia and a white mucous vaginal discharge are normal. A small amount of vaginal bleeding, known as pseudomenstruation, may occur as a result of the sudden withdrawal of the mother's hormones at birth. It is not a result of trauma. Because the finding is normal, the pediatrician will not need to check the infant. Telling the mother that the finding is nothing to be concerned about is not the most appropriate option, because it is nontherapeutic.

A nurse is discussing birth control methods with a client who is trying to decide which method to use. The nurse should focus on which major factor that will provide the motivation needed for consistent implementation of a birth control method? A. Family planning goals B. Personal preference C. Work and home schedules D. Desire to have children in the future

B Rationale: Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. The nurse should educate the client about the various contraceptive methods available so that expressions of preference may be based on understanding. The desire to have children in the future, work and home schedules, and family planning goals may affect the choice of birth control method but are not motivating factors.

A nurse is performing an admission assessment on an older client who will be seen by a primary health care provider in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? A. Document the client's concern in the medical record. B. Ask the client about medications he is taking. C. Tell the client that sexual dysfunction is a normal age-related change. D. Report the client's concern to the primary health care provider.

B Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client's concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking.

A nurse taking the vital signs of a client who delivered a healthy newborn infant 4 hours ago notes that the client's oral temperature is 101.2° F (38.4° C). Which action would be appropriate? A. Documenting the findings B. Notifying the primary HCP C. Retaking the temperature rectally D. Telling the client that the temperature at this level is expected at this time

B Rationale: Temperatures up to 100.4° F (38.0° C) in the 24 hours after birth are often 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. However, a temperature higher than 100.4° F indicates an infection, and the primary health care provider should be notified. Although the nurse also would document the findings, the appropriate action would be to contact the primary health care provider. There is no useful reason for taking the temperature rectally. Telling the client that her increased temperature is expected at this time is incorrect.

The nurse immediately assesses the newborn infant to determine the Apgar score and records the findings. Nursing Assessment Notes, Heart rate: 130 beats/min, Respiratory effort: weak cry, Muscle tone: minimal flexion of extremities, Reflex irritability: Grimacing in response to nasal/oral bulb suction, Skin color: Normal body skin but blue extremities. What is his Apgar score at one minute? A. 5 B. 6 C. 2 D. 4

B Rationale: The Apgar score is a method used to express the findings of a rapid assessment of the newborn as he or she enters extrauterine life. The five categories are heart rate (counted apically with the use of a stethoscope or by means of palpation of the umbilical cord), respiratory effort (by means of observation of respiration and crying effort), muscle tone (based on the degree of movement and flexion of the extremities), reflex irritability (based on the newborn's response to bulb/catheter suction of the nasopharynx), and general skin color. Apgar evaluations are made at 1 and 5 minutes after birth.

A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? A. "The diaphragm can be inserted as long as 6 hours before intercourse." B. "I can leave the diaphragm in place as long as I want after intercourse." C. "I need to reapply spermicidal cream with repeated intercourse." D. "The diaphragm needs to be filled with spermicidal cream before insertion."

B Rationale: The diaphragm may be inserted as long as 6 hours before intercourse and must remain in place for at least 6 hours after. Because of the risk of toxic shock syndrome, the diaphragm must not remain in place for more than 24 hours. The diaphragm must be filled with spermicidal cream or jelly before insertion, and the spermicide must be reapplied before intercourse is repeated.

An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? A. "The number of sweat glands and blood vessels decreases in the normal aging process." B. "A loss of melanin occurs in the normal aging process." C. "The skin on the scalp becomes thin, causing moisture to escape." D. "It is caused by hereditary factors."

B Rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair.

A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nagele's Rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? A. October 17, 2016 B. November 17, 2016 C. September 17, 2016 D. December 17, 2017

B Rationale: The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? A. Simple board games and puzzles B. Blocks and push-pull toys C. Videos and cutting-and-pasting toys D. Finger paints and card games

B Rationale: Toys for the toddler should meet the child's needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push-pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler.

Select all: Which findings are normal age-related physiological changes? A. Increased HR B. Diminished visual acuity C. Decline in long-term memory D. Increased susceptibility to UTIs E. Increased incidence of awakening after onset of sleep

B, D Rationale: Anatomic changes in the eye affect the older individual's visual ability acuity, sometimes leading to problems in carrying out activities of daily living. Light adaptation is diminished and visual fields reduced. The heart rate slows and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Sleep pattern changes are common with increasing age. Older persons generally experience an increased incidence of awakening after sleep onset.

The lactation consultant nurse visits Annie to discuss breastfeeding and to observe as Annie breastfeeds her baby. The nurse discusses mastitis, its signs and symptoms, how to prevent it, and what to do if it occurs. Which statements by Annie reflect understanding of the information that is being presented? Select all that apply. A. "It won't hurt to miss a few feedings if I'm too tired." B. "I'll wash my nipples carefully before and after feedings." C. "I should expect to have sore, cracked nipples when starting to breastfeed." D. "If I get mastitis, I'll have to stop breastfeeding from that side until it is healed." E. "If my nipples are sore, I should apply warm water compresses before breastfeeding." F. "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours."

B, E, F Rationale: Mastitis, a breast infection, may affect one or both breasts. It may be prevented with the use of proper technique and positioning for breastfeeding, preventing the development of cracked nipples, and emptying the breasts at regular intervals by means of breastfeeding, manual expression, or breast pumping. Cleanliness is also important. If mastitis occurs, breastfeeding is still recommended, because it is important to empty the breasts. Missed feedings can contribute to mastitis. The nipples may be sore (but not cracked) at the beginning of breastfeeding, and warm water compresses may be comforting before breastfeeding.

The nurse provides information to Marilyn about follow-up care while taking the oral contraceptives. Which instruction should the nurse provide to Marilyn? A. She will need to have yearly liver function studies. B. She will need to have a yearly cardiovascular test for 2 years and one every other year thereafter. C. She will need to have a yearly pelvic and breast examination, Papanicolaou (Pap) smear, and blood pressure measurement. D. She will need to have a pelvic and breast examination and Pap smear every 2 years, but her blood pressure should be checked every 6 months.

C Rationale: A woman who takes oral contraceptives should have a yearly pelvic and breast examination, Pap smear, and blood pressure measurement. Cardiovascular tests and liver function studies are not necessary.

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist in developing which psychosocial stage? A. Autonomy B. A sense of trust C. A sense of industry D. Initiative

C Rationale: According to Erikson, the central task of the school-age years is the development of a sense of industry. The school-age child replaces fantasy play with "work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of infancy. Development of autonomy is the task of toddlerhood. Development of initiative is the task of the preschooler.

The mother of a 9-year-old child who is 5 feet 1 inch (155 cm) in height asks a nurse about car safety seats. What should the nurse tell the mother to use? A. Rear convertible seat B. Forward-facing car seat C. Rear seat using lap and shoulder seat belts D. Front booster seats

C Rationale: All infants and toddlers should ride in a Rear-Facing Car Seat until they are at least 2 years of age or until they reach the highest weight or height allowed by their car seat's manufacturer. ​Any child who has outgrown the rear-facing weight or height limit for their convertible car seat should use a Forward-Facing Car Seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. All children whose weight or height is above the forward-facing limit for their car seat should use a Belt-Positioning Booster Seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches (145 cm) in height and are between 8 and 12 years of age.​ When children are old enough and large enough for the vehicle seat belt to fit them correctly, they should always use Lap and Shoulder Seat Belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? A. The procedure will take about 2 hours. B. The obstetrician will locate the fetus with the use of the Leopold's maneuvers. C. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. D. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.

C Rationale: Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Leopold's maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.

A nurse who has just assisted in the delivery of a newborn infant is providing initial care to the infant. Which action should the nurse take to prevent heat loss by way of conduction in the infant? A. Keeping the infant away from drafty areas B. Keeping the infant away from cold windows C. Warming the hands before touching the infant D. Drying the infant as soon as possible after birth

C Rationale: Conduction of heat away from the body occurs when a newborn comes in direct contact with an object that is cooler than his or her skin. Placing an infant on a cold surface or touching the newborn with cold hands or a cold stethoscope causes this type of heat loss. Convective heat loss occurs when heat is transferred to air surrounding the infant. Keeping the infant out of drafts and maintaining warm environmental temperatures help prevent this type of heat loss. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. An infant placed near a cold window loses heat by way of radiation. Heat loss by way of evaporation occurs when a wet surface is exposed to air. Drying the infant as soon as possible after birth and after bathing prevents this type of heat loss.

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? A. Drinking eight 8-oz (240 ml) glasses of fluid each day will reduce the risk of contracting influenza. B. It is best to do grocery shopping and other errands late in the day C. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses D. They must stay in the house and ask a neighbor or family member to run their errands

C Rationale: During peak influenza season, older clients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage clients to do their shopping and other errands early in the morning, when crowds are smaller, or to have someone else shop for them. The use of a scarf across the nose and mouth can help reduce the transmission of airborne viruses. Drinking eight 8-oz (240 ml) glasses of fluid a day will not reduce the risk of contracting influenza; however, it will prevent dehydration if illness occurs.

A nurse teaches the husband of a woman who is in the active phase of stage 1 labor how to perform effleurage on his wife. Which observation by the nurse indicates that the spouse is performing the procedure correctly? A. The man lightly pushes on his wife's sacral area with his fist. B. The man exerts steady pressure on his wife's abdomen during a contraction. C. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. D. The man exerts light pressure with the heel of the hand over the area of the uterine fundus.

C Rationale: Effleurage (light massage) and counter pressure are two methods that provide pain relief to a woman in the first stage of labor. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during a contraction. It is used to distract the woman from contraction pain. Counter pressure is steady pressure, applied to the sacral area with the fist or heel of the hand, that may help the woman cope with the sensations of internal pressure and pain in the lower back. Therefore the other options are incorrect.

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "Fluoride supplementation is not necessary until permanent teeth come in." B. "I can mix the food in my infant's bottle if he won't eat the food." C. "Egg white should not be given to my infant because of the risk for an allergy." D. "Meats are really important for iron, and I should start feeding meats to my infant right away."

C Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant's intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant's intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the pediatrician's preference, fruits and vegetables may be introduced first.

At 30 weeks' gestation, Janice is seen in the maternity clinic for a follow-up visit. The nurse checks the fundal height. Which measurement does the nurse expect to see? A. 20 cm B. 26 cm C. 30 cm D. 34 cm

C Rationale: From 22 weeks to term, the fundal height, which is measured in centimeters, is roughly equal (plus or minus 2 cm) to the gestational age of the fetus in weeks. Therefore, because this client is at 30 weeks' gestation, her fundal height would be 30 (plus or minus 2 cm). If fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause of the unexpectedly large uterine size. If fundal height is less than expected on the basis of gestational age, the estimated date of delivery must be confirmed. If the dates are accurate, further assessment may be necessary to determine whether the fetus' growth is inadequate.

A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? A. Gravida 2, para 4 B. Gravida 3, para 5 C. Gravida 4, para 2 D. Gravida 5, para 3

C Rationale: Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? A. Male condom B. Diaphragm C. Sterilization D. Spermicide

C Rationale: If family planning goals have already been met, sterilization of the male or female partner may be desirable. When sexual activity is limited, use of a spermicide, condom, or diaphragm may be most appropriate.

A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? A. She should cover the discoloration with makeup. B. She should come to the clinic immediately to be checked. C. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. D. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen.

C Rationale: Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign/symptom is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? A. Discouraging social interaction, particularly at bedtime B. Encouraging at least one daytime nap C. Encouraging bedtime reading or listening to music D. Discouraging the use of a night light at bedtime

C Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a night light will foster an environment that is both helpful and safe.

The mother of a newborn is upset because her newborn has a birthmark on the left side of the forehead. The mother, on being told that it is a nevus vasculosus (strawberry mark), asks the nurse whether the mark is permanent. What should the nurse tell the mother? A. It is a permanent mark B. It will need to be removed with surgery C. It will disappear on its own by the early school years D. It is nothing to be concerned about because it is so small

C Rationale: Nevus vasculosus (strawberry mark) consists of enlarged capillaries in the outer layers of the skin. It is dark red and raised, with a rough surface, giving it a strawberry appearance. Usually located on the head, a nevus vasculosus may grow larger for 5 to 6 months but usually disappears by the early school years. No treatment is necessary.

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? A. The child no longer has temper tantrums. B. The child can eat using a fork and knife. C. The child can remove his or her own clothing. D. The child has been walking for 2 years.

C Rationale: Signs of physical readiness for toilet training include the following: The child can remove his/her own clothing; is willing to let go of a toy when asked; is able to sit, squat, and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2 years, and an absence of temper tantrums are not signs of physical readiness.

A nurse has just assisted in the delivery of a newborn infant and is preparing to help deliver the placenta. For which sign/symptom of placental separation does the nurse monitor the woman? A. A soft, boggy fundus B. Shortening of the umbilical cord C. Vaginal fullness on examination D. Assumption of a discoid shape by the uterus

C Rationale: Signs/symptoms of placental separation include a firmly contracting fundus; a change in the uterus from a discoid to a globular shape, which occurs as the placenta moves into the lower uterine segment; a sudden gush of dark blood from the introitus; apparent lengthening of the umbilical cord as the placenta descends to the introitus; the presence of vaginal fullness (placenta) on vaginal or rectal examination; and the presence of fetal membranes at the introitus.

A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? A. The umbilical cord holds two veins and one artery. B. Fetal blood circulation takes place strictly in the placenta. C. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. D. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.

C Rationale: The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "The drop side needs to be impossible for my infant to release." B. "I need to keep large toys out of the crib." C. "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body." D. "Wood surfaces on the crib need to be free of splinters and cracks."

C Rationale: The distance between slats must be no more than 2 ⅜ inches (6 cm) to prevent entrapment of the infant's head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch (.5 cm). The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib, because an older infant may use them as steps to climb over the side, possibly resulting in serious injury.

A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? A. Suggest to the pediatrician that a skull x-ray be performed B. Tell the mother that the infant is growing faster than expected C. Document these measurements in the infant's health-care record D. Suspect the presence of hydrocephalus

C Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect.

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? A. Allow the toddler to play with other children in the nursing unit playroom B. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room C. Keep hospital routines as similar as possible to those at home D. Spend as much time as possible with the toddler

C Rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler's usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler's sense of control and security and ease feelings of helplessness and fear.

A nurse provides instructions to a breastfeeding mother about measures that will provide relief from breast engorgement. Which statement by the mother indicates an understanding of the instructions? A. "I should switch to formula to feed my baby for 1 week." B. "I need to stop breastfeeding until the engorgement resolves." C. "I should apply warm packs to my breasts before each feeding." D. "I need to apply ice packs to my breasts 20 minutes before a feeding."

C Rationale: When breast engorgement occurs, the breasts become edematous, hard, and tender, making feeding and even movement painful. The nurse should encourage the woman to begin breastfeeding early after delivery and to feed frequently as a means of preventing engorgement. The nurse would also teach the woman about the application of cold and heat, massage, and breastfeeding techniques. Cold is used after feeding to reduce edema and pain. Heat is applied just before feedings to increase vasodilation and milk flow. Massage of the breasts causes release of oxytocin and increases the speed of milk release. This decreases the length of time that the infant nurses on painful breasts.

A nurse provides information to a female client about the use of a diaphragm. Which statement by the client indicates a need for further information? A. "I need to use spermicidal cream with the diaphragm." B. "I shouldn't leave the diaphragm in for more than 24 hours." C. "I have to insert the diaphragm immediately before intercourse." D. "The diaphragm should stay in place for at least 6 hours after intercourse."

C Rationale: When in place over the cervical os, the diaphragm blocks access of sperm to the cervix. Because the device does not fit tightly enough to completely block penetration of sperm, however, it must be filled with spermicidal jelly or cream before insertion. (Spermicide must be reapplied with repeated intercourse.) It may be inserted as long as 6 hours before intercourse. The diaphragm must remain in place for at least 6 hours after intercourse, but, because of the risk of toxic shock syndrome, it should not be left in place for more than 24 hours.

A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. A. Perform the exercise while urinating. B. Perform the exercise once only after urinating. C. Repeat the contraction-relaxation cycle 30 times a day. D. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. E. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.

C, D Rationale: Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.

As Penny's labor progresses, the obstetrician performs another examination and concludes that Penny is in the second stage of labor. Which of these assessment findings should the nurse expect to note at this stage of labor? Select all that apply. A. Descent of 1-2 cm B. Pink to bloody mucus C. Increase in bloody show D. Increased urge to bear down E. Cervical dilation of 10 cm with 100% effacement F. Contractions 2 min apart, 90 sec in duration

C, D, E, F Rationale: The second stage of labor is the stage during which the infant is born. The stage begins with cervical dilation of 10 cm and complete (100%) cervical effacement. The increase in bloody show, increased urge to bear down, and increased duration and frequency of contractions are part of the descent, or active pushing, phase of the second stage of labor. Mucus that is pink to bloody and descent of 1 to 2 cm are findings that are characteristic of the first stage of labor.

After checking Penny again, the obstetrician decides to perform rupture of the membranes (ROM). Penny is told that she will need to empty her bladder first and then remain in bed after the procedure. Which of these assessment findings after ROM indicate that the amniotic fluid is normal? Select all that apply. A. Strong odor B. Thick and cloudy C. Watery consistency D. Greenish-brown color E. Pale and straw-colored

C, E Rationale: Normal amniotic fluid is pale or straw-colored and of a watery consistency, without a strong odor. Thick, cloudy amniotic fluid or a strong odor might indicate an intrauterine infection. Greenish-brown fluid reflects the presence of meconium and may indicate that the fetus has had a hypoxic episode.

That evening, during an assessment, the nurse finds that Annie's uterine fundus is above the umbilicus and to the left of the midline of the abdomen. What action by the nurse is a priority? A. Performing fundal massage B. Performing a sterile urinary catheterization C. Assessing the lochia on Annie's perineal pad D. Assisting Annie to the bathroom to help her void

D Rationale: A full bladder causes the uterus to be displaced above the level of the umbilicus and off to one side of the midline of the abdomen. It may also lead to uterine atony, because it prevents the uterus from contracting normally. The priority nursing intervention is to assist the woman in emptying her bladder as soon as possible, either by taking her to the bathroom or offering a bedpan if she is not ambulatory. Fundal massage should be performed, if the fundus is boggy, once the bladder has been emptied. Catheterization is done only if the woman is unable to void after measures have been taken to encourage urination. Assessing the lochia does not address the problem.

A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours B. Report the findings to the primary health care provider C. Ask the primary health care provider for a prescription for a nighttime sedative D. Document the findings in the medical record

D Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the primary health care provider. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns.

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? A. Schedule an appointment with a dentist for a dental evaluation B. Obtain an over-the-counter (OTC) topical medication for gum-pain relief C. Rub the infant's gums with baby aspirin that has been dissolved in water D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

D Rationale: Although sometimes asymptomatic, teething is often signaled by behaviors such as nighttime awakening, daytime restlessness, increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health-care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the healthcare provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child's age, can relieve discomfort.

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which? A. Keeping up with schoolwork B. Obtaining adequate rest and sleep C. Obtaining adequate nutrition D. Body image

D Rationale: Body image is of particular importance to an adolescent. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. They are not concerned about obtaining adequate nutrition and tend to eat fast foods and junk foods and may experiment with weight-management techniques such as fasting, diet pills and laxatives, self-induced vomiting, and fad diets. Keeping up with schoolwork may be important to some teenagers, but it is not usually the primary concern. Along with engaging in increasingly independent activities, teenagers tend to stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep is not teenagers' primary concern.

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? A. Ensuring that most of the diet consists of liquids B. Encouraging the client to feed herself C. Consulting with the health care provider regarding feeding through an enteral tube D. Monitoring the client during meals to ensure that food is swallowed

D Rationale: Clients with dysphagia must be assisted during meals, and the nurse should carefully observe the client to ensure that foods are successfully swallowed instead of being trapped in the mouth. The diet should be nutritionally balanced and consist of both solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration pneumonia. Thickeners can be added to liquids, because thin liquids are most difficult to swallow for clients with dysphagia. Clients with severe dysphagia may require enteral tube feedings, but there is no information in the question to indicate that the dysphagia is severe.

A nurse reviews the health history of a client who will be seeing the primary health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? A. The client has hyperlipidemia B. The client is being treated for HTN C. The client has type II DM D. The client has been treated for breast cancer

D Rationale: Combination oral contraceptives contain both estrogen and progestin and are contraindicated during pregnancy and for women who have (or have a history of) the following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary-artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They are used with caution in women with diabetes mellitus, women who smoke heavily, women with risk factors for cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating elective surgery in which thrombosis might be expected.

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations? A. Once a year B. Whenever a new primary tooth erupts C. Every 3 months D. Every 6 months

D Rationale: Dental examinations for a 4- to 5-year-old child should be conducted every 6 months. Every 3 months, once a year, and whenever a new primary tooth erupts are all incorrect.

During the 30-week follow-up visit, the nurse assesses Janice and asks, "How are you feeling these days?" Which of these statements from Janice would indicate that further assessment is needed? Select all that apply. A. "I spend so much time going to the bathroom!" B. "I haven't been sleeping well for several days." C. "I've noticed that I get out of breath after I vacuum the floors." D. "Since yesterday I've noticed that the baby isn't moving as much." E. "I've noticed that my fingers and face have been swollen when I wake up in the morning."

D Rationale: During the second and third trimesters of pregnancy, certain signs and symptoms may indicate complications. Any change in the pattern or frequency of fetal movements should be investigated immediately to detect or rule out fetal jeopardy. Swelling of the face or fingers may indicate a hypertensive condition or preeclampsia. Discomforts that are expected during this trimester of pregnancy include insomnia, frequent urination (caused by impingement of the enlarging uterus on the bladder, resulting in reduced bladder capacity), and shortness of breath (resulting from limitation of diaphragm movement by the enlarging uterus).

The nurse notes documentation in the record of a client in labor that the client is completely effaced. Based on this information, what conclusion should the nurse make? A. The cervical os is completely dilated. B. The client will require induction with the use of oxytocin. C. Enlargement of the cervical canal that occurs during the first stage of labor is complete. D. The shortening and thinning of the cervix that occurs during the first stage of labor is complete.

D Rationale: Effacement is the shortening and thinning of the cervix that occurs during the first stage of labor. Dilation is the enlargement of the cervical os and cervical canal during the first stage. When the cervical os is completely dilated, the client is prepared for the birth of the baby. Induction is the deliberate initiation of uterine contractions that stimulates labor. In this situation, induction is not necessary.

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? A. Stethoscope B. Fetoscope C. Pulse ox on the client and a fetoscope D. Doppler transducer

D Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds.

A nurse observes an assistive personnel (AP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the AP performs which action? A. Uses facial expressions or gestures B. Speaks at a normal rate and volume C. Uses short sentences D. Overarticulates words

D Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the AP avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the AP to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The AP should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues.

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents? A. To restrict any social privileges until the behavior stops B. That their daughter will need to see a child psychologist if the behavior continues C. That this type of behavior is usually the result of parents' spoiling a child D. That this is normal behavior for an adolescent

D Rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self-centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent.

Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? A. The result of the Rh factor screen is normal. B. Because the Rh factor is not present, no additional testing is necessary. C. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. D. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.

D Rationale: If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age-related finding? A. Thick skin on the lower legs B. Bounding dorsalis pedis pulse C. Thin, ridged toenails D. Loss of hair on the lower legs

D Rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become more difficult to find. They would not be bounding. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs) also occur normally with aging.

A subarachnoid (spinal) block is administered to a woman before a cesarean section. During the immediate postpartum period, which vital sign does the nurse check most closely as part of monitoring for adverse effects of the block? A. Temperature B. Apical pulse C. Respirations D. BP

D Rationale: The injection site for a subarachnoid block is in the spinal subarachnoid space at L3-L5. This type of anesthesia, administered just before birth, relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities. The adverse effects of a subarachnoid block are maternal hypotension, bladder distention, and postural puncture headache. Although the nurse would monitor the woman's temperature, pulse, and respirations, the blood pressure must be monitored most closely.

Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? A. The primary health care provider should be notified immediately if breast engorgement occurs B. If the oral tablets are not successful, the medication will be administered intravenously C. The couple should engage in coitus once a week during treatment D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

D Rationale: Multiple births (usually twins) occur in a small percentage (8% to 10%) of clomiphene-facilitated pregnancies, and the couple should be informed of this. The medication is available in 50-mg tablets for oral use. There is no available intravenous form. Breast engorgement is a common side effect of the medication that reverses after medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus at least every other day during this time.

Penny's labor is progressing slowly because her contractions are inadequate, so the obstetrician prescribes intravenous oxytocin to augment labor. While the oxytocin is being administered, the nurse monitoring Penny closely, notes that her contractions are occurring every 3 minutes and are lasting 60 seconds. Which action should the nurse take? A. Contact the obstetrician B. Stop the oxytocin infusion C. Transport Penny to the delivery room D. Maintain the current dosage of oxytocin

D Rationale: Oxytocin, a hormone naturally produced by the posterior pituitary gland, stimulates uterine contractions and may be used to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions. The nurse monitors the client closely and maintains the dosage if the intensity of contractions results in intrauterine pressure of 40 to 90 mm Hg (as shown by an internal monitor), if the duration of contractions is 40 to 90 seconds, if the contractions come at 2- to 3-minute intervals, or if cervical dilation of 1 cm/hr occurs in the active stage. Oxytocin is stopped if uterine hyperstimulation or a non-reassuring pattern of fetal heart rate occurs. There is no need to contact the obstetrician at this time or to transport Penny to the delivery room, because she is still progressing through the first stage of labor.

A nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? A. The normal aging process increases the production of surfactant B. The normal aging process increases respiratory system compliance C. The normal aging process decreases the number of alveoli and increases the function of those remaining D. The normal aging process decreases an older client's ability to clear secretions

D Rationale: Respiratory changes related to the normal aging process decrease an older adult's ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished.

A school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? A. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime B. Brush and floss their teeth every morning and at bedtime C. Brush their teeth every morning and at bedtime D. Brush and floss their teeth after meals and at bedtime

D Rationale: School-age children are able to assume responsibility for their own dental hygiene. Good oral health habits tend to be carried into the adult years, helping prevent cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by flossing between the teeth should be done after meals and before bedtime. It is important that parents set up a routine schedule for the child that promotes good daily oral hygiene and gives them responsibility for their own dental care.

A nurse prepares to teach a pregnant woman to perform tailor-sitting exercises. Which instruction should the nurse provide to the client? A. Lie flat on the back and place both feet against a wall. B. Position self on the hands and knees and arch the back five times in a 30-second period. C. Sit with the legs straight, press the knees toward the floor, and hold the position for 10 seconds. D. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes.

D Rationale: Tailor-sitting exercises are useful in alleviating heartburn and shortness of breath or dyspnea. The woman sits on the floor, bends her knees, places the soles together, uses her thigh muscles to press the knees to the floor, and holds the position for 5 to 15 minutes. The other options are incorrect descriptions of this exercise.

Which intervention does the nurse immediately implement for a newborn with an Apgar score of 6 at 1 minute? A. None B. Preparing for neonatal resuscitation C. Supporting spontaneous respiratory efforts D. Gently stimulating the infant by rubbing his back and administering oxygen

D Rationale: The Apgar scoring method is used for quick evaluation of the newborn infant's cardiorespiratory adaptation after birth. A 1-minute score of 4 to 7 means that the nurse should take measures to stimulate the infant, such as gently rubbing the infant's back, while administering oxygen. Resuscitation is necessary for scores of 0 to 3. For Apgar scores of 8 to 10, no action is needed except for continued observation and support of the infant's own spontaneous efforts.

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client? A. Spouse's children from a previous marriage B. Foster children and their parents C. Spouse and spouse's parents D. Aunts, uncles, grandparents, and cousins

D Rationale: The extended family includes relatives, (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of husband and wife and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint living situation.

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? A. Wait 15 minutes and then recheck the FHR B. Notify the primary health care provider of the finding C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time D. Document the findings

D Rationale: The normal fetal heart depends on gestational age (usually higher in the first trimester) and is generally in the range of 120 to 160 beats per minute. A FHR of 160 beats per minute is within the normal range, so documentation is the only action indicated.

A woman who has just delivered a baby asks the nurse when she may resume sexual intercourse. Which response should the nurse give to the client? A. Intercourse may be resumed at any time after delivery. B. Intercourse may not be resumed until menstruation returns. C. Intercourse may not be resumed until after the 6-week checkup with the obstetrician. D. Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed.

D Rationale: The woman who has just given birth should be told that she may safely resume sexual intercourse by the second to fourth week after delivery, when bleeding has stopped and the episiotomy has healed. The other options are incorrect.

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "Yes, your infant is protected from all infections." B. "The transfer of your antibodies protects your infant until the infant is 12 months old." C. "If you breastfeed, your infant is protected from infection." D. "The immune system of an infant is immature, and the infant is at risk for infection."

D Rationale: Transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T-lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection.

A newborn taken to the nursery for assessment and placed in the infant warmer while he is cleansed. Vital signs are stable, and he settles easily. Before taking the infant back to his mother, the nurse administers an injection of vitamin K. Which injection route and site are appropriate? A. IV B. SQ, upper arm C. IM, dorsogluteal muscle D. IM, vastus lateralis muscle

D Rationale: Vitamin K, when administered for the prevention of hemorrhagic disease in the newborn, is given intramuscularly in the vastus lateralis. It is never given as a subcutaneous injection, and intravenous vitamin K is only used in special situations, such as for a preterm infant who does not have any muscle mass to support injections. The dorsogluteal muscle is very small and poorly developed in newborns, and the sciatic nerve is much more prominent at this age. Additionally, the deltoid muscle of a newborn does not have enough mass for an injection.

A nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult? A. Young adults ignore their risk for a serious illness B. Young adults are unable to afford health insurance C. Young adults are exposed to hazardous substances D. Young adults ignore physical symptoms and postpone seeking health care

D Rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance.

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? A. Industry vs. inferiority B. Initiative vs. guilt C. Trust vs. mistrust D. Autonomy vs. doubt and shame

D Rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their wills and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their own wills but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool-age child. Industry versus inferiority is the developmental task of the school-age child.

Which precautions should the nurse take to prevent newborn abduction? Select all that apply. A. Placing the newborn's crib close to the mother's door B. Instructing the mother to carry the newborn to the nursery after feeding C. Closing the hospital room door if the infant needs to be left unattended D. Questioning unknown person(s) who are carrying large bags or packages E. Ensuring that all health care personnel wear proper name (identification) badges

D, E Rationale: Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking a nurse to attend to the newborn if no one is available to watch the newborn (the newborn is never left unattended). The nurse should monitor the environment closely and question any suspicious or unknown person, especially one carrying a large bag or package that could contain an infant.

A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? A. Checking the woman's blood pressure B. Calling the obstetrician to the examining room C. Placing a cool cloth on the woman's forehead D. Assisting the client into a lateral recumbent position

D. Rationale: When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Signs/symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.

A nurse is performing an ophthalmoscopic examination of an older client. Which age-related change would the nurse expect to note while viewing the retina? A. Clear fundus B. Red BVs C. Yellow-orange optic disc D. Yellow spots near the macula

D. Yellow spots near the macula Rationale: Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula. Red blood vessels, a clear fundus, and a yellow-orange optic disc are all normal findings, not age-related changes.