OB Exam 1

The pregnant patient asks the nurse when the male and female reproductive organs begin to differentiate. The nurse's best answer is, "Differentiation happens at: 1. "4 weeks." 2. "8 weeks." 3. "14 weeks." 4. "20 weeks."

Correct Answer: 2 Rationale 2: Reproductive organs begin differentiation at 8 weeks

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Respiratory rate 60, crackles present bilaterally 2. Pulse rate 145, systolic murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds

Correct Answer: 4 Rationale 4: Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention.

The nurse seeing a patient at 28 weeks' gestation explains that a 1-hour glucose screen must be done, and that normal results are: (select all) 1. 135 mg/dl. 2. 120 mg/dl. 3. 155 mg/dl. 4. 130 mg/dl. 5. 140 mg/dl.

Correct Answer: 1,4,5 should be 130ish to 150ish

A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone? 1. Estrogen 2. Progesterone 3. FSH 4. LH

Correct Answer: 2 Rationale 2: Progesterone decreases uterine motility and contractility; thus a lack of progesterone will affect the ability of the uterus to be prepared for implantation after the ovum is fertilized.

The prenatal clinic nurse is caring for a 15-year-old primiparous patient who is at 8 weeks' gestation. The patient asks the nurse why she is supposed to gain so much weight. What is the best response by the nurse? 1. "Gaining 25-35 pounds is recommended for healthy fetal growth." 2. "It's what your certified nurse-midwife recommended for you." 3. "Inadequate weight gain delays lactation after delivery." 4. "Weight gain is important to ensure that you get enough vitamins."

Correct Answer: 1 Rationale 1: For an appropriate-weight woman, 25-35 pounds of weight gain is recommended for optimal fetal growth and development.

The nurse has completed a community presentation about the changes of pregnancy, and knows that the lesson was successful when a community member states, "One probable or objective change of pregnancy is: 1. "Enlargement of the uterus." 2. "Hearing the baby's heart rate." 3. "Increased urinary frequency." 4. "Nausea and vomiting."

Correct Answer: 1 Rationale 1: Objective or probable changes of pregnancy are those that the examiner can detect but are not diagnostic because they can be caused by issues other than pregnancy. Enlargement of the uterus is a probable change.

In evaluating information taught about conception and fetal development, the patient verbalizes understanding about transportation time of the zygote through the fallopian tube and into the cavity of the uterus with which statement? 1. "It will take at least 3 days for the egg to reach the uterus." 2. "It will take 8 days for the egg to reach the uterus." 3. "It will only take 12 hours for the egg to go through the fallopian tube." 4. "It will take 18 hours for the fertilized egg to implant in the uterus."

Correct Answer: 1 Rationale 1: "It will take at least 3 days for the egg to reach the uterus" is the correct statement.

A 27-year-old married woman is 16 weeks pregnant and has an abnormally low maternal serum alpha-fetoprotein test. Which statement indicates that the couple understands the implications of this test result? 1. "We have decided to have an abortion if this baby has Down syndrome." 2. "If we hadn't had this test, we wouldn't have to worry about this baby." 3. "I'll eat plenty of dark green leafy vegetables until I have the ultrasound." 4. "The ultrasound should be normal because I'm under the age of 35."

Correct Answer: 1 Rationale 1: A low maternal serum alpha-fetoprotein test can indicate trisomy 18 or trisomy 21 (Down syndrome). Many couples abort a fetus that has a genetic abnormality that significantly affects quality of life or has multiple medical problems. Down syndrome is more likely to develop in the fetuses of women over the age of 35 at delivery, but is not limited to this age group.

The nurse is preparing a patient for amniocentesis. Which statement would indicate that the patient clearly understands the risks of an amniocentesis? 1. "I might go into labor early." 2. "It could produce a congenital defect in my baby." 3. "Actually, there are no real risks to this procedure." 4. "The test could stunt my baby's growth."

Correct Answer: 1 Rationale 1: Amniocentesis has the potential for causing preterm labor

The pregnant patient and her partner are both 40 years old. The nurse is explaining the options of chorionic villus sampling (CVS) and amniocentesis for genetic testing. The nurse should correct the patient if she states: 1. "Amniocentesis results are available sooner than CVS results are." 2. "CVS carries a higher risk of limb abnormalities." 3. "Amniocentesis cannot detect a neural tube defect." 4. "CVS is performed through my belly or my cervix."

Correct Answer: 1 Rationale 1: Amniocentesis results take longer to process than do CVS results.

A postpartum client calls the clinic to report that her 3-day-old baby girl has a spot of blood on her diaper. The best explanation for the nurse to give is that this finding is due to: 1. Withdrawal of maternal hormones. 2. A urinary infection. 3. An immature immune system. 4. Physiologic jaundice.

Correct Answer: 1 Rationale 1: As maternal hormones clear the newborn, it is not unusual to find blood on the diapers of a female newborn. This is referred to as pseudomenstruation.

The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? 1. Brazelton's Neonatal Behavioral Assessment Scale 2. Ballard Maturity Scale 3. Dubowitz gestational age scale 4. Ortolani's maneuver

Correct Answer: 1 Rationale 1: Brazelton's Neonatal Behavioral Assessment Scale assesses the newborn's state changes, temperament, and individual behavior patterns.

The nurse is presenting a preconception counseling class. The nurse instructs the participants that niacin intake should increase during pregnancy to promote metabolic coenzyme activity. The nurse will know that teaching has been effective if a patient suggests which food as a source of niacin? 1. Fish 2. Apples 3. Broccoli 4. Milk

Correct Answer: 1 Rationale 1: Dietary sources of niacin include meats, fish, and enriched grains.

Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Amount and area of vernix coverage 2. Creases on the sole 3. Size of the areola 4. Body surface temperature

Correct Answer: 1 Rationale 1: Drying the baby after birth will disturb the vernix and potentially alter the score when using the Ballard gestational assessment tool. The nurse should document the amount and coverage of the vernix before drying the newborn.

The nurse educator knows that teaching about reproduction has been effective when a student states, "Once the ovum has entered the fallopian tube, movement of the ovum through the fallopian tube and toward the uterus is facilitated by: 1. "Estrogen-induced tubal peristalsis." 2. "Progesterone-induced cervical mucus changes." 3. "Motions of the sphincters at the fallopian tubes." 4. "Movements of the corona radiata of the ovum."

Correct Answer: 1 Rationale 1: Estrogen-induced tubal peristalsis is a part of a well-functioning tubal transport system and involves active fimbriae close to the ovary, peristalsis of the tube created by the muscular layer, ciliated currents beating toward the uterus, and the proximal contraction and distal relaxation of the tube caused by different types of prostaglandins.

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection

Correct Answer: 1 Rationale 1: Eye prophylaxis medication may be withheld for 1 hour following birth. This allows for eye contact between the newborn and the family, which enhances parent-newborn bonding.

The nurse is preparing a prenatal class about infant feeding methods. The maternal nutritional requirements for breastfeeding and formula-feeding will be discussed. What statement should the nurse include? 1. "Breastfeeding requires a continued high intake of protein and calcium." 2. "Formula-feeding mothers should protect their health with a lot of calcium." 3. "Producing breast milk requires calories, but any source of food is fine." 4. "Formula-feeding mothers need a high protein intake to avoid fatigue."

Correct Answer: 1 Rationale 1: Lactation requires calories, along with increased protein and calcium intake.

The nurse is planning an educational session for pregnant vegans. What information should the nurse include? 1. Eating beans and rice provides complete protein needs. 2. Soy is not a good source of protein for vegans. 3. Rice contains a high level of vitamin B12. 4. Vegan diets are excessively high in iron.

Correct Answer: 1 Rationale 1: Neither rice nor beans and other legumes alone contain complete protein requirements. Consuming both in a day provides for complete protein needs.

A pregnant patient asks the nurse, "What is this 'knuckle test' that is supposed to tell whether my baby has a genetic problem?" The nurse correctly explains that: 1. "The term is nuchal, and it refers to the neck. The test is a special ultrasound that measures the thickness of the back of the baby's neck." 2. "You will need to ask the physician for an explanation." 3. "It tests for Down syndrome." 4. It tests for neural tube defects."

Correct Answer: 1 Rationale 1: Nuchal translucency detects fetal chromosome anomalies, including trisomy 21, 18, and 13, and Turner's syndrome. The test measures the thickness of the tissue over the posterior of the baby's neck.

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. The nurse should explain to the mother that: 1. Physiologic jaundice is normal, and peaks at this age. 2. The newborn's liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring.

Correct Answer: 1 Rationale 1: Physiologic jaundice peaks at about the third day of life, as a result of the breaking down and excretion of red blood cells (RBCs).

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? The infant's mother had: 1. Ruptured membranes for 36 hours. 2. An IVof lactated Ringer's solution. 3. A labor that lasted 12 hours. 4. A cesarean birth with her last child.

Correct Answer: 1 Rationale 1: Prolonged rupture of membranes (greater than 12 hours) increases the risk for maternal endometritis and newborn sepsis.

A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? 1. Arm recoil 2. Square window sign 3. Scarf sign 4. Popliteal angle

Correct Answer: 1 Rationale 1: Recoil time is slower in fatigued newborns. Therefore, arm recoil is best elicited after the first hour of birth so the newborn has time to recover from the stress of birth.

The prenatal clinic nurse is explaining test results to a patient who has had an assessment for fetal well-being. Which statement indicates that the patient understands the test result? 1. "The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby." 2. "The reactive nonstress test means that my baby is not growing because of a lack of oxygen." 3. "Because my contraction stress test was positive, we know that my baby will tolerate labor well." 4. "My biophysical profile score of 6 points to everything being normal and healthy for my baby."

Correct Answer: 1 Rationale 1: The Doppler velocimetry test looks at blood flow through the umbilical artery. A normal result indicates there is no vasospasm decreasing blood flow to the placenta; therefore, the baby is getting an adequate blood supply.

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm

Correct Answer: 1 Rationale 1: The average circumference of the head at birth is 32—37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size.

The nurse is presenting a class to women who are currently pregnant or are planning pregnancy in the near future. Which patient's statement indicates that additional teaching is required? 1. "The older a woman is when she conceives, the safer the pregnancy is." 2. "Pregnant teens can have additional nutritional needs." 3. "A woman whose sisters all had hypertension will be watched carefully." 4. "Pregnancy may be more difficult to achieve spontaneously in my 40s."

Correct Answer: 1 Rationale 1: The health risks associated with pregnancy vary by age. Hypertension and gestational diabetes are more common in women over 35. Spontaneous pregnancy is more difficult in one's 40s, and infertility treatment becomes more likely to be required to achieve pregnancy.

The nurse teaching a class on reproductive anatomy knows that no further instruction is needed when a student shows an understanding of the pelvic cavity divisions by stating: 1. "The true pelvis is made up of the sacrum, coccyx, and innominate bones." 2. "The false pelvis consists of the inlet, the pelvic cavity, and the outlet." 3. "The true pelvis is the portion above the pelvic brim." 4. "The relationship between the false pelvis and the fetal head is of paramount importance."

Correct Answer: 1 Rationale 1: The true pelvis is made up of the sacrum, the coccyx, and the two innominate bones (or hip bones).

The nurse is preparing for a postpartum home visit. The patient has been home for a week, is breastfeeding, and experienced a third-degree perineal tear after vaginal delivery. The nurse should assess the patient for: 1. Dietary intake of fiber and fluids. 2. Dietary intake of folic acid and prenatal vitamins. 3. Return of hemoglobin and hematocrit levels to baseline. 4. Return of protein and albumin to predelivery levels.

Correct Answer: 1 Rationale 1: This mother needs to avoid the risk of constipation. She might be hesitant to have a bowel movement due to anticipated pain from the perineal tear, and constipation will decrease the healing of the laceration.

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. The best response by the nurse is: 1. "His head is molded from fitting through the birth canal. It will become more round." 2. "We refer to that as 'cone head,' which is a temporary condition that goes away." 3. "It might mean that your baby sustained brain damage during birth, and could have delays." 4. "I think he looks just like you. Your head is much the same shape as your baby's."

Correct Answer: 1 Rationale 1: This statement is accurate and directly answers the father's question.

The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful? 1. "Taking baths will help my perineum feel less sore each day." 2. "If I develop heavy bleeding, I should take my temperature." 3. "My bowel movements should resume in a week." 4. "I will go back to the doctor in 4 days for my RhoGAM shot."

Correct Answer: 1 Rationale 1: Tub soaks or sitz baths will facilitate perineal healing.

Why is it important for the nurse to understand the type of family that a client comes from? Select all that apply. 1. Family structure can influence finances and the ability to purchase nutritious foods. 2. Many types of families exist, and it is important to address the persons who hold power within the family. 3. The nurse can anticipate which problems a client will experience based on the type of family the client has. 4. Understanding if the client's family is nuclear or blended will help the nurse teach the client the appropriate information. 5. The values of the family will be predictable if the nurse knows what type of family the client is a part of.

Correct Answer: 1,2 Rationale 1: Dual-career/dual-earner families tend to have more stable finances, while single-parent families tend to have lower incomes. Nutrition impacts fetal growth and development, and nutritious foods tend to be more costly than nutrient-poor or junk food. Thus understanding the type of family can help the nurse determine the best education for the client. Rationale 2: Understanding the family power is important so that the nurse will address the appropriate person(s). This will facilitate effective communication, as the nurse will be perceived as respectful of the family

A patient at 32 weeks' gestation comes to the clinic with urinary burning and frequency. The nurse explains that urinary tract infections are common in pregnancy due to: (select all) 1. Ureteral atonia. 2. Stasis of urine. 3. Increased glomerular filtration rate. 4. Excretion of amino acids. 5. Increased clearance of urea.

Correct Answer: 1,2 Rationale 1: Ureteral atonia is a cause of urinary tract infections during pregnancy. Rationale 2: The stasis of urine in the ureter during pregnancy is a cause of urinary tract infection.

The nurse is teaching about reproduction, and explains that the purposes of meiosis are to: (select all) 1. Produce gametes. 2. Reduce the number of chromosomes. 3. Introduce genetic variability. 4. Produce cells for tissue repair. 5. Divide somatic cells into new cells with identical characteristics.

Correct Answer: 1,2,3 Rationale 1: In the production of reproductive cells (gametes), there is a reduction of chromosome numbers by half (from diploid [46] to haploid [23]), so that when fertilization occurs, the normal diploid number is restored. This introduces genetic variability.

The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include: (select all) 1. Prematurity. 2. Maternal intrapartum fever. 3. Membranes ruptured for longer than 18 hours. 4. A previously infected infant with GBS disease. 5. An older mother having her first baby.

Correct Answer: 1,2,3,4 Rationale 1: Prematurity is a risk factor. Rationale 2: Maternal intrapartum fever is a risk factor. Rationale 3: Prolonged rupture of membranes is a risk factor. Rationale 4: A previously infected infant increases the risk.

The nurse is counseling a group of first-trimester patients on diet increases that are necessary during pregnancy. Which information would be necessary to tell the pregnant women? (select all) 1. An increase of protein is necessary to provide amino acids necessary for fetal development. 2. Protein contributes to the body's overall energy metabolism. 3. The recommended protein during pregnancy is 60 g each day. 4. The increased amount of protein that a pregnant woman needs is 8 g a day. 5. The quality of protein is as important as the amount.

Correct Answer: 1,2,3,5 Rationale 1: Protein is important for fetal development, increased maternal blood volume, and growth of other maternal tissues. Rationale 2: Protein is needed for overall energy metabolism. Rationale 3: The amount of protein recommended each day during pregnancy is 60 g. Rationale 5: Protein quality can vary. For instance, meat protein has more amino acids than does plant protein.

Remedies for back pain in pregnancy that are supported by research evidence and may safely be taught to any pregnant woman by the nurse include: (select all) 1. Pelvic tilt. 2. Water aerobics. 3. Sit-ups. 4. Proper body mechanics. 5. Maintaining good posture.

Correct Answer: 1,2,4,5 Rationale 1: Pelvic tilt is a remedy supported for use throughout pregnancy. Rationale 2: Water aerobics are supported for use throughout pregnancy. Rationale 4: Engaging in proper body mechanics is an appropriate remedy supported for use throughout pregnancy. Rationale 5: Maintaining good posture is a remedy supported for use throughout pregnancy.

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? (select all) 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the baby's ability to focus.

Correct Answer: 1,2,5 Rationale 1: Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. Rationale 2: The nurse massages the eyelid gently to distribute the ointment. Rationale 5: The eye medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces.

When caring for a new mother after cesarean birth, what complications would the nurse anticipate? (select all) 1. Back pain 2. Blood clots 3. Deep vein thrombosis 4. Pulmonary embolism 5. Perineal edema

Correct Answer: 2,3,4 Rationale 2: Immobility after delivery increases the risk of blood clots. Rationale 3: Immobility and increased production of coagulation factors after delivery increase the risk of deep vein thrombosis. Rationale 4: Immobility and increased production of coagulation factors after delivery increase the risk of clot formation and subsequent pulmonary embolus.

The pregnant patient states she does not want "to take all these supplements." What recommendations could the nurse make for the patient? (select all) 1. "Folic acid has been found to be essential for minimizing the risk of neural tube defects." 2. "You do not have to take these supplements if you think you are healthy enough." 3. "Most women do not have adequate intake of iron pre-pregnancy, and iron needs increase with pregnancy." 4. "These medications do the same thing. I will call your physician to cancel one of your medications." 5. "You should take the folic acid, but the vitamins are not that important."

Correct Answer: 1,3 Rationale 1: Research has shown such a strong correlation between decreased folic acid/folate intake and the risk of neural tube defects that all women thinking of becoming pregnant are encouraged to begin taking a 400 mcg supplement 2 months before attempting conception. Rationale 3: Iron is essential because most pregnant women do not have adequate intake of iron before pregnancy.

The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? (select all) 1. Administer a dose of 0.5-1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, -inch needle for the injection. 4. Protect the medication bottle from light. 5. Give the medication prior to a circumcision procedure.

Correct Answer: 1,3,4,5 Rationale 1: This is the correct dosage for vitamin K. Rationale 3: This is the right size needle to use. Rationale 4: This medication must be kept away from light to protect its stability. Rationale 5: This is a prophylactic injection given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.

The clinic nurse is assessing how the prenatal patient is meeting developmental tasks. The nurse uses Rubin's tasks, which include: (select all) 1. Ensuring safe passage through pregnancy, labor, and birth. 2. Turning in on oneself to focus on the child. 3. Seeking commitment and acceptance of self as mother to the infant. 4. Completing the tasks of nesting at the appropriate time. 5. Seeking acceptance of the child by others.

Correct Answer: 1,3,5 Rationale 1: The tasks Rubin identified form the basis for a mutually gratifying relationship with the baby, and include ensuring safe passage through pregnancy, labor, and birth. Rationale 3: The tasks Rubin identified form the basis for a mutually gratifying relationship with the baby, and include seeking commitment and acceptance of self as mother. Rationale 5: The tasks Rubin identified form the basis for a mutually gratifying relationship with the baby, and include seeking acceptance of the child by others.

The nurse recognizes the importance of the interaction between the nervous and endocrine systems in the female reproductive cycle. The interaction involves the: (select all) 1. Hypothalamus. 2. Adrenal cortex. 3. Ovaries. 4. Thyroid. 5. Anterior pituitary.

Correct Answer: 1,3,5 The female reproductive cycle is controlled by complex interactions between the nervous and endocrine systems and their target tissues. These interactions involve the hypothalamus, ovaries, and ant. pituitary

The OB-GYN nurse teaches a first-time pregnant patient that functions of the amniotic fluid include: (select all) 1. Allowing fetal freedom of movement. 2. Releasing heat to control fetal temperature. 3. Acting as an extension of fetal extracellular space. 4. Providing a water source for the fetus to swallow. 5. Acting as a wedge during labor.

Correct Answer: 1,3,5 Rationale 1: A primary function of amniotic fluid is to prevent adherence of the embryo-fetus to the amnion (decreasing the chance of amniotic band syndrome) to allow freedom of movement. Rationale 3: A primary function of amniotic fluid is to act as an extension of fetal extracellular space. Rationale 5: A primary function of amniotic fluid is to act as a wedge during labor.

Student nurses in their obstetrical rotation are learning about fertilization and implantation. The process of implantation is characterized by which statements? (select all) 1. The trophoblast attaches itself to the surface of the endometrium. 2. The most frequent site of attachment is the lower part of the anterior uterine wall. 3. Between days 7 and 10, the zona pellucida disappears, and the blastocyst implants itself in the uterine lining. 4. The lining of the uterus thins below the implanted blastocyst. 5. The cells of the trophoblast grow down into the uterine lining, forming the chorionic villi.

Correct Answer: 1,3,5 Rationale 1: During implantation, the trophoblast attaches itself to the surface of the endometrium, between days 7 and 10. Rationale 3: Between days 7 and 10, the zona pellucida disappears, and the blastocyst implants itself in the thickened uterine lining. Rationale 5: The cells of the trophoblast grow down into the thickened lining, forming the chorionic villi.

A patient at 34 weeks' gestation complains about pyrosis. The nurse teaches the patient that approaches to relieve the pyrosis include: (select all) 1. Eat small, frequent meals. 2. Use high-sodium antacids. 3. Avoid fried, fatty foods. 4. Take sodium bicarbonate after meals. 5. Do not lie down after eating.

Correct Answer: 1,3,5 Rationale 1: Pyrosis (heartburn) can be relieved by eating small, more frequent meals. Rationale 3: Avoiding fatty, fried foods can relieve pyrosis. Rationale 5: Sitting up after meals will help decrease the pyrosis.

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalhematoma based on which characteristics? (select all) 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line.

Correct Answer: 1,4 Rationale 1: A cephalhematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. It can appear between the first and second day after birth. Rationale 4: Cephalhematomas can be unilateral or bilateral, but do not cross the suture lines.

A patient is admitted to the labor suite. It is essential that the nurse assess the woman's status in relation to which infectious diseases? (select all) 1. Hepatitis B 2. Rubeola 3. Varicella 4. Group B streptococcus 5. HIV/AIDS

Correct Answer: 1,4,5 Rationale 1: Hepatitis B should be assessed. Rationale 4: Streptococcus B should definitely be assessed. Rationale 5: HIV/AIDS should be assessed.

The nurse is reviewing preconception questionnaires in charts. Which couple are the most likely candidates for preconceptual genetic counseling? 1. Wife is 30 years old, husband is 31 years old. 2. Wife and husband are both 29 years old, first baby for husband, wife has a normal 4-year-old. 3. Wife's family has a history of hemophilia. 4. Single 32-year-old woman is using donor sperm.

Correct Answer: 3 Rationale 3: Hemophilia is a sex-linked disorder; therefore, the couple with hemophilia in the wife's family is at risk for hemophilia in male offspring.

A patient who is experiencing her first pregnancy has just completed the initial prenatal examination with a certified nurse-midwife. Which statement indicates that the patient needs additional information? 1. "Because we heard the baby's heartbeat, I am undoubtedly pregnant." 2. "Since I haven't felt the baby move yet, we don't know whether I'm pregnant." 3. "My last period was 2 months ago, which means I'm 2 months along." 4. "The increased size of my uterus means that I am finally pregnant."

Correct Answer: 2 Rationale 2: Fetal movement is a subjective, or presumptive, change of pregnancy, and is not a reliable indicator in the early months or pregnancy.

A nurse teaches newly pregnant patients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is: 1. Estrogen. 2. Human chorionic gonadotropin (hCG). 3. Progesterone. 4. Luteinizing hormone.

Correct Answer: 2 Rationale 2: When the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete human chorionic gonadotropin (hCG) hormone to maintain the corpus luteum.

A woman is at 32 weeks' gestation. Her fundal height measurement at this clinic appointment is 26 centimeters. After reviewing her ultrasound results, the healthcare provider asks the nurse to schedule the patient for a series of sonograms to be done every 2 weeks. The nurse should make sure that the patient understands that the main purpose for this is to: 1. Assess for congenital anomalies. 2. Evaluate fetal growth. 3. Determine fetal presentation. 4. Rule out a suspected hydatidiform mole.

Correct Answer: 2 Rationale 2: At 32 weeks' gestation the fundal height should measure 32 cm. When there is a discrepancy between actual and ideal fundal height, the purpose of serial ultrasounds is to monitor fetal growth.

A patient has preeclampsia. She is 36 weeks pregnant, and comes to the high-risk screening center for a contraction stress test. The nurse should explain to the patient that the contraction stress test is being done to determine: 1. What effect her hypertension has had on the fetus. 2. Whether the fetus will be able to tolerate labor. 3. Whether fetal movement increases with contractions. 4. What effect contractions will have on her blood pressure.

Correct Answer: 2 Rationale 2: Contraction stress tests are performed to assess the ability of the fetus to tolerate labor.

The nurse anticipates that the physician will most likely order a cervico-vaginal fetal fibronectin test for which patient? 1. The patient at 34 weeks' gestation with gestational diabetes 2. The patient at 32 weeks' gestation with regular uterine contractions 3. The patient at 37 weeks' multi-fetal gestation 4. The patient at 20 weeks' gestation with ruptured amniotic membranes

Correct Answer: 2 Rationale 2: Fetal fibronectin is tested by swabbing the cervico-vaginal secretions. The presence of this substance is a strong predictor of preterm delivery, and thus is performed on women at risk for preterm delivery. Regular uterine contractions can be preterm labor. The patient experiencing preterm contractions should be tested for the presence of fetal fibronectin.

The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? 1. Lanugo mainly gone, little vernix across the body 2. Prominent clitoris, enlarging minora, anus patent 3. Full areola, 5-10mm bud, pinkish-brown in color 4. Skin opaque, cracking at wrists and ankles, no vessels visible

Correct Answer: 2 Rationale 2: Labia minora enlarge as the infant achieves greater gestational age, and the clitoris will be covered at term.

The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings? 1. Document the findings on the prenatal chart. 2. Have the physician see the patient today. 3. Instruct the patient to avoid direct sunlight. 4. Analyze previous thyroid hormone lab results.

Correct Answer: 2 Rationale 2: Mottling of the skin is indicative of poor oxygenation and a circulation problem. Skin and nail bed pallor can indicate either hypoxia or anemia. These abnormalities must be reported to the physician immediately.

The nurse is presenting a class to pregnant patients. The nurse asks, "The fetal brain is developing rapidly, and the nervous system is complete enough to provide some regulation of body function on its own, at which fetal development stage?" It is clear that education has been effective when a participant responds: 1. "The 17th-20th week." 2. "The 25th-28th week." 3. "The 29th-32nd week." 4. "The 33rd-36th week."

Correct Answer: 2 Rationale 2: Nervous system function that is complex enough to provide body function regulation occurs around the 25th-28th week, which is when a fetus has a good chance of survival if born.

A patient at 37 weeks' gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates a fetal heart rate baseline of 150 with three contractions in 10 minutes, no decelerations, and accelerations four times in 1 hour. This test would be considered a: 1. Positive nonstress test. 2. Negative contraction stress test. 3. Positive contraction stress test. 4. Negative nonstress test.

Correct Answer: 2 Rationale 2: The desired result is a negative contraction stress test; this means that there are three contractions in 10 minutes, without decelerations.

The nurse receives a phone call from a patient who claims she is pregnant. The patient reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the patient's estimated date of delivery (EDD) be? 1. Nov. 13 2. Jan. 17 3. Jan. 10 4. Dec. 3

Correct Answer: 2 Rationale 2: The due date is Jan. 17. Nagele's rule is to add 7 days to the last menstrual period and subtract 3 months. The last menstrual period is April 10; therefore Jan. 17 is the EDD.

A patient at 36-weeks' gestation is complaining of dyspnea when lying flat. The clinical reason for this complaint is: 1. Maternal hypertension. 2. Fundal height. 3. Hydramnios. 4. Congestive heart failure.

Correct Answer: 2 Rationale 2: The dyspnea is resulting from the pressure of the enlarging uterus on the diaphragm

A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? 1. "Don't worry. Babies go through a lot of these little phases." 2. "Your son is in the second alert phase. He'll wake up soon." 3. "Your son is exhausted from being born, and will sleep 6 more hours." 4. "Your breastfeeding efforts have caused excessive fatigue in your son."

Correct Answer: 2 Rationale 2: The first alert phase lasts about 30 minutes after birth, followed by decreased activity and then sleep that will last about 2-4 hours.

The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. The nurse's best response is: 1. "I'm checking to make sure the baby has all of its parts." 2. "This assessment looks at both physical aspects and the nervous system." 3. "This assessment checks the baby's brain and nerve function." 4. "Don't worry. We perform this check on all the babies."

Correct Answer: 2 Rationale 2: The gestational age assessment evaluates both external physical characteristics and neurologic or neuromuscular development.

The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be: 1. Temperature 97.9°F. 2. Respirations 68 breaths/minute. 3. Blood pressure 72/44. 4. Heart rate 156 beats/min.

Correct Answer: 2 Rationale 2: The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.

A postpartum patient has just received a rubella vaccination. The patient demonstrates understanding of the teaching associated with administration of this vaccine when she states: 1. "I will need another vaccination in 3 months." 2. "I must avoid getting pregnant for 1 month." 3. "This will prevent me from getting chickenpox." 4. "This will protect my newborn from getting the measles."

Correct Answer: 2 Rationale 2: The patient must avoid pregnancy for at least 4 weeks after receiving the rubella vaccine.

During a prenatal examination, an adolescent patient asks, "How does my baby get air?" The nurse would give correct information by saying: 1. "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences." 2. "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream." 3. "The blood from the placenta is carried through the umbilical artery, which penetrates the abdominal wall of the fetus." 4. "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy."

Correct Answer: 2 Rationale 2: The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into the maternal bloodstream.

The nurse teaching a high school class explains that during the menstrual cycle, the vascularity of the uterus increases and the endometrium becomes prepared for a fertilized ovum. In which phase of the menstrual cycle does this occur? 1. Menstrual 2. Proliferative 3. Secretory 4. Ischemic

Correct Answer: 2 Rationale 2: The proliferative phase refers to the buildup of the endometrium as blood supply and uterine size are increased.

A woman pregnant with twins asks the nurse about differences between identical and fraternal twins. The nurse explains that since it has been determined that she is having a boy and a girl, they are fraternal, and there will be: 1. One placenta, two amnions, and two chorions. 2. Two placentas, two amnions, and two chorions. 3. Two placentas, one amnion, and two chorions. 4. Two placentas, two amnions, one chorion.

Correct Answer: 2 Rationale 2: This is the correct answer. Fraternal twins have two placentas, two amnions, and two chorions. There are always two placentas, but sometimes they will fuse together.

The nurse has received the end-of-shift report on the postpartum unit. Which patient should the nurse see first? 1. Multip, 2nd day post-cesarean, moderate lochia serosa 2. Primip, day of delivery, fundus firm 2 cm above umbilicus 3. Multip, 1st postpartum day, 4 cm diastasis recti abdominis 4. Primip, 1st postpartum day, hypoactive bowel sounds all quadrants

Correct Answer: 2 Rationale 2: This patient is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding.

The nurse is reviewing amniocentesis results. Care was appropriate if the patient: 1. Who is Rh-positive received RhoGAM after the amniocentesis. 2. Was monitored for 30 minutes after completion of the test. 3. Began vaginal spotting before leaving for home after the test. 4. Identified that she takes insulin before each meal and at bedtime.

Correct Answer: 2 Rationale 2: Twenty to 30 minutes of fetal monitoring is performed to assess fetal well-being and to rule out injury of the fetus or placenta during the exam.

A pregnant teenage patient is diagnosed with iron-deficiency anemia. Which nutrient should the nurse encourage her to take to increase iron absorption? 1. Vitamin A 2. Vitamin C 3. Vitamin D 4. Vitamin E

Correct Answer: 2 Rationale 2: Vitamin C is known to enhance the absorption of iron from meat and nonmeat sources.

The nurse teaches a patient that luteinizing hormone (LH) is important in the ovarian cycle for: (select all) 1. Proliferation of the endometrial mucosa. 2. Ovulation. 3. Corpus luteum development. 4. The graafian follicle. 5. Maturation of the ovarian follicle.

Correct Answer: 2,3,4 Rationale 2: During the follicular phase, the primordial follicle matures under the influence of FSH and LH until ovulation occurs. Rationale 3: The corpus luteum develops under the influence of LH during the luteal phase. Rationale 4: A mature graafian follicle appears on about the 14th day of the ovarian cycle under dual control of FSH and LH.

Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? (select all) 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home.

Correct Answer: 2,3,4 Rationale 2: Folding the diaper down can prevent contamination of the area and promote drying. Rationale 3: Keeping the stump clean and dry can reduce the risk of infection. Rationale 4: The nurse needs to educate the parents about the signs and symptoms of infection.

The nurse is preparing a brochure for couples considering pregnancy after the age of 35. Which statements should be included? (select all) 1. There is a decreased risk of Down syndrome. 2. Preexisting medical conditions can complicate pregnancy. 3. Very preterm births are more common. 4. Amniocentesis can be performed to detect genetic anomalies. 5. Gestational diabetes is no longer a risk.

Correct Answer: 2,3,4 Rationale 2: The older a woman is, the more likely she is to have developed chronic healthcare issues such as type 2 diabetes or hypertension. The presence of chronic conditions can further complicate pregnancy in women over 35. Rationale 3: Very preterm births and low birth weight are more common in pregnancy of women over 35. Rationale 4: Amniocentesis is offered to women over 35 due to the increased risk of trisomy 18 and 21.

Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? (select all) 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins

Correct Answer: 2,3,4 Rationale 2: The results of an infectious disease screening could determine that the infant might need isolation, antimicrobial medication, or further assessment. Rationale 3: Gestational diabetes puts the newborn at risk for certain problems. Rationale 4: Prolonged rupture of the membranes can result in the newborn's developing an infection or other problems that will necessitate special care.

The nurse in the prenatal clinic will tell the 38-weeks'-gestation patient to lie on her left side when the patient complains of: (select all) 1. Nausea. 2. Pallor. 3. Clamminess. 4. Constipation. 5. Dizziness.

Correct Answer: 2,3,5 Rationale 2: Vena caval syndrome can cause pallor, which is relieved when the patient turns to lie on her left side. Rationale 3: Vena caval syndrome can cause clamminess, which is relieved when the patient turns to lie on her left side. Rationale 5: Vena caval syndrome can cause dizziness, which is relieved when the patient turns to lie on her left side.

A pregnant patient at 28 weeks' gestation asks the nurse what her baby is like at this stage of pregnancy. The nurse responds that the baby: (select all) 1. Is laying down subcutaneous fat. 2. Is now opening and closing her eyes. 3. Could now breathe on her own. 4. Has fingernails and toenails. 5. Is forming surfactant needed for lung function.

Correct Answer: 2,3,5 Rationale 2: At 28 weeks, the eyes begin to open and close. Rationale 3: At 28 weeks, the baby can breathe. Surfactant needed for breathing at birth is formed. Rationale 5: At 28 weeks, the baby has the surfactant formed needed for breathing.

The nurse is speaking to students about changes in maternal-newborn care. One change is that self-care has gained wide acceptance with patients, the healthcare community, and third-party payers due to research findings that suggest that it: 1. Shortens newborn length of stay. 2. Decreases use of home health agencies. 3. Reduces healthcare costs. 4. Decreases the number of emergency department visits.

Correct Answer: 3 Rationale 3: Research indicates self-care significantly reduces healthcare costs.

The patient in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best? 1. "Lack of menses and breast enlargement are presumptive signs of pregnancy." 2. "The changes you are describing are definitely indicators that you are pregnant." 3. "Lack of menses can be caused by many things. We need to do a pregnancy test." 4. "You're probably not pregnant, but we can check it out if you like."

Correct Answer: 3 Rationale 3: This is a true statement, and addresses that these changes could be caused by things other than pregnancy.

The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means: 1. Fetal lungs are still immature. 2. The fetus has a congenital anomaly. 3. Fetal lungs are mature. 4. The fetus is small for gestational age.

Correct Answer: 3 Rationale 3: A 2:1 L/S ratio indicates that the risk of respiratory distress syndrome (RDS) is very low and that the fetus's lungs are mature.

A 58-year-old father and a 45-year-old mother gave birth to a baby boy 2 days ago. The nurse assesses a single palmar crease and low-set ears on the newborn. The nurse plans to counsel the couple about which chromosomal abnormality? 1. Trisomy 13 2. Trisomy 18 3. Trisomy 21 4. Trisomy 26

Correct Answer: 3 Rationale 3: A single palmar crease and low-set ears are characteristics of trisomy 21 (Down syndrome).

RhoGAM is given to the postpartum patient for the purpose of: 1. Preventing congenital birth defects through vaccination. 2. Preventing or avoiding the chronic state of infection of hepatitis B. 3. Preventing sensitization from the fetomaternal transfusion of Rh-positive fetal red blood cells. 4. Preventing the spread of Group B streptococcal infection in the neonate.

Correct Answer: 3 Rationale 3: Administering a RhoGAM injection to an Rh-negative mother who delivered an Rh-positive infant helps prevent sensitization from the fetomaternal transfusion of Rh-positive fetal red blood cells.

The couple has had an ultrasound at 19 weeks' gestation, and their fetus was found to have anencephaly. The nurse is completing counseling for the couple on the ultrasound findings. Which statement indicates that additional teaching is needed? 1. "Our baby has an incomplete brain, and might not be born alive." 2. "This problem is not caused by one of us having a genetic problem." 3. "We won't know whether something is wrong until the baby's chromosomes are tested." 4. "Waiting until our 30s did not cause this problem to develop."

Correct Answer: 3 Rationale 3: Anencephaly is clearly visualized with ultrasound, and does not require genetic testing to verify a diagnosis.

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, grunting respirations 4. 4-hour-old female who has not voided

Correct Answer: 3 Rationale 3: Grunting respirations are an indication of respiratory distress. This infant needs further assessment, and possibly intervention, immediately.

During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as: 1. A negative test. 2. A reactive test. 3. A nonreactive test. 4. An equivocal test.

Correct Answer: 3 Rationale 3: In a nonreactive stress test, the reactivity criteria are not met. Because this patient experienced a deceleration during the test, this is considered nonreactive

The nurse determines the fundus of a postpartum patient to be boggy. Initially, the nurse should: 1. Document the findings. 2. Catheterize the patient. 3. Massage gently and reassess. 4. Call the physician immediately.

Correct Answer: 3 Rationale 3: Massaging gently and reassessing would be the initial intervention to prevent postpartum hemorrhage.

The nurse is providing nutritional counseling for a postpartum patient with a hemoglobin of 8.0. Which statement indicates that additional teaching is necessary? 1. "My iron is low, but it will increase as I take iron supplements." 2. "I need to increase food sources that contain iron." 3. "If I drink lots of milk, I will increase my iron level faster." 4. "I might feel less energetic and tire more easily while my iron is low."

Correct Answer: 3 Rationale 3: Milk does not contain iron; it contains calcium. Increased calcium intake will not increase hemoglobin levels. Further, iron should not be taken with milk, as the iron will not be absorbed.

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? The student nurse: 1. Listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles. 2. Checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. 3. Determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. Counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

Correct Answer: 3 Rationale 3: Neonatal assessment proceeds in a head-to-toe fashion.

A new father asks the nurse to describe what his baby will experience while sleeping and awake. The best response is: 1. "Babies have several sleep and alert states. Keep watching, and you'll notice them." 2. "You might have noticed that your child was in an alert awake state for an hour after birth." 3. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 4. "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

Correct Answer: 3 Rationale 3: Teaching the parents how to recognize the two sleep stages helps them tune in to their infant's behavioral states.

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as: 1. Nevus vasculosus. 2. Nevus flammeus. 3. Telangiectatic nevi. 4. A Mongolian spot.

Correct Answer: 3 Rationale 3: Telangiectatic nevi (stork bites) are pale pink or red spots that appear on the eyelids, nose, lower occipital bone, or the nape of the neck.

A pregnant patient confides to the nurse that she is eating laundry starch daily. The nurse should assess the patient for: 1. Alopecia. 2. Weight loss. 3. Iron-deficiency anemia. 4. Fecal impaction.

Correct Answer: 3 Rationale 3: The ingestion of non-nutritive food sources is called pica. Eating these non-nutritive substances has been found to interfere with the absorption of iron.

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette

Correct Answer: 3 Rationale 3: The most common form of heat loss is evaporation. Evaporation occurs when water is converted to a vapor. Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation

On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to: 1. The taking-hold phase. 2. Postpartum hemorrhage. 3. The taking-in phase. 4. Epidural anesthesia.

Correct Answer: 3 Rationale 3: The taking-in phase, which occurs during the 1st day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest.

The nurse is caring for a 15-year-old patient who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? 1. The patient's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby when assessing him. 4. A discussion on contraceptive methods is the first topic of teaching.

Correct Answer: 3 Rationale 3: This action helps the patient learn about her baby as an individual and facilitates maternal-infant attachment. This is the highest priority.

The nurse is observing the meal selections of a group of pregnant and postpartal patients. One meal consists of a cup of skim milk, soy burger on a bun, baked beans, 8 ounces of water, four carrot sticks, and a mixed fresh fruit cup. For which patient is this meal the best choice? 1. 27-year-old primip, 8 weeks' gestation, Hgb 11.0 2. 30-year-old multip 2 days postpartum, bottle-feeding 3. 15-year-old primip, 1 day postpartum, breastfeeding 4. 20-year-old multip, 32 weeks' gestation, reports fatigue.

Correct Answer: 3 Rationale 3: This is the best patient for this meal. Because the patient is an adolescent, she needs a high-protein diet, and because she is breastfeeding, she needs a high-calcium diet. The meal described is high in calcium and protein: Milk, soy, and beans all are sources of protein, while milk and soy are good sources of calcium.

The patient with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the patient understands the need for this additional antepartal fetal surveillance? 1. "After the ultrasound, my partner and I will decide how to decorate the nursery." 2. "During the ultrasound we will see which of us the baby looks like most." 3. "The ultrasound will show whether there are abnormalities with the baby's spine." 4. "The blood test wasn't run correctly, and now we need to have the sonogram."

Correct Answer: 3 Rationale 3: Ultrasound is used to detect neural tube defects. An abnormal serum quadruple screen is not the result of a lab error, and can indicate either an open neural tube defect or trisomy 18 or 21.

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses: 1. Ortolani's maneuver. 2. Babinski's reflex. 3. The clavicle. 4. The Galant reflex.

Correct Answer: 3 Rationale 3: When the Moro reflex is elicited, the newborn straightens both arms and hands outward with the knees flexed, then slowly return the arms to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle. If the clavicle is fractured, the response is demonstrated on the unaffected side only.

The OB-GYN nurse is assessing a pregnant patient, and recognizes genetic amniocentesis will be indicated. The nurse makes this conclusion because the indications for genetic amniocentesis are: (select all) 1. Maternal age under 35. 2. Ultrasound visualization at 8 weeks. 3. One child with a chromosome abnormality. 4. A family history of neural tube defects. 5. Both parents with an abnormal chromosome.

Correct Answer: 3,4,5 Rationale 3: Parents who have a child with a chromosomal anomaly have an increased chance of having a second child with the abnormality. Rationale 4: Family history of neural tube defects is an indication for genetic amniocentesis. Rationale 5: If both parents carry an autosomal recessive disease, they have a 25% chance with each pregnancy that the fetus will be affected.

When caring for the newborn after a vaginal delivery, the nurse needs to be able to identify the respiratory changes that occur during the transition of the fetus to extrauterine life. Which factors does the nurse recognize as contributing to the changes in the newborn's lung function after birth? (select all) 1. Adequate lung development and production of surfactant 2. Marked decrease in pulmonary circulation 3. Inspiratory gasp triggered by the elevation in PCO2 and decrease in pH and PO2 4. Stimulation of skin nerve endings due to chilling 5. Chemical stimulator associated with transient asphyxia of the fetus

Correct Answer: 3,4,5 Rationale 3: This is the natural result of the cessation of placental gas exchange when the cord is clamped. Rationale 4: A significant decrease in ambient temperature after birth results in sudden chilling of the moist newborn, which stimulates skin nerve endings. The newborn response is rhythmic breathing. Rationale 5: The chemical stimulator acts on the aortic and carotid chemoreceptors, initiating impulses that trigger the brain's respiratory center.

A nurse is examining different nursing roles. Which example best illustrates an advanced practice nursing role? 1. A registered nurse who is the manager of a large obstetrical unit 2. A registered nurse who is the circulating nurse at surgical deliveries (cesarean sections) 3. A clinical nurse specialist working as a staff nurse on a motherbaby unit 4. A clinical nurse specialist with whom other nurses consult for her expertise in caring for high-risk infants

Correct Answer: 4 Rationale 4: A clinical nurse specialist with whom other nurses consult for expertise in caring for high-risk infants is working in an advanced practice nursing role. This nurse has specialized knowledge and competence in a specific clinical area, and is master's-prepared.

The nurse is providing guidance for a woman in her second trimester of pregnancy and telling her about some of the signs and symptoms that she might experience. Which statement by the patient indicates that further teaching is necessary? 1. "During the third trimester, I might have frequent urination." 2. "During the third trimester, I might have heartburn." 3. "During the third trimester, I might have back pain." 4. "During the third trimester, I might have a persistent headache."

Correct Answer: 4 Rationale 4: A persistent headache is not normal or expected. This could be related to the complication of preeclampsia.

When preparing nutritional instruction, which pregnant patient would the nurse consider the highest priority? 1. 40-year-old gravida 2 2. 22-year-old primigravida 3. 35-year-old gravida 4 4. 15-year-old nulligravida

Correct Answer: 4 Rationale 4: Adolescent patients typically are still in their own growth cycle. With pregnancy, they suddenly need increased nutrition for themselves and the fetus. This places them at greatest risk for malnutrition.

The nurse teaching the phases of the menstrual cycle should include the fact that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and the blood supply to the endometrium is reduced in which phase? 1. Menstrual phase 2. Proliferative phase 3. Secretory phase 4. Ischemic phase

Correct Answer: 4 Rationale 4: In the ischemic phase, the corpus luteum begins to degenerate, and as a result, both estrogen and progesterone levels fall. Small blood vessels rupture, and the spiral arteries constrict and retract, causing a deficiency of blood in the endometrium, which becomes pale.

The nurse explains to a preconception class that if only a small volume of sperm is discharged into the vagina, an insufficient quantity of enzymes might be released when they encounter the ovum. In that case, pregnancy would probably not result, because: 1. Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus. 2. The block to polyspermy (cortical reaction) would not occur. 3. The fertilized ovum would be unable to implant in the uterus. 4. Sperm would be unable to penetrate the zona pellucida of the ovum.

Correct Answer: 4 Rationale 4: It takes hundreds of acrosomes (the result of the acrosomal reaction) to rupture and release enough hyaluronic acid to clear the way for a single sperm to penetrate the ovum's zona pellucida successfully. If only a small amount of sperm were released, there most likely would be an insufficient quantity of acrosomes to penetrate the zona pellucida of the ovum and allow fertilization.

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. The nurse is most concerned about: 1. Neonatal jaundice. 2. Polycythemia. 3. Neonatal hyperthermia. 4. Respiratory distress.

Correct Answer: 4 Rationale 4: Nasal flaring, facial grimacing, and excessive mucus are signs of respiratory distress.

A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant patient. When should the first dose of RhoGAM be administered? 1. After the birth of the infant 2. 1 month postpartum 3. During labor 4. At 28 weeks' gestation

Correct Answer: 4 Rationale 4: Since transplacental hemorrhage is possible during pregnancy, an antibody screen is performed on an Rh-negative woman at 28 weeks' gestation. If she has no antibody titer, she is given an IM injection of 300 mcg Rh immune globulin (RhoGAM).

During the assessment, the nurse notices that an African American baby has a darker, slightly bluish-hued patch about 5 cm 7 cm on the buttocks and lower back. What is the nurse's next action? 1. Call the Department of Social Services (DSS) to report this sign of abuse. 2. Confer with the physician about the possibility of a bleeding tendency. 3. Ask the mother about the cause of the bruise. 4. Chart the presence of a Mongolian spot.

Correct Answer: 4 Rationale 4: The nurse will chart the presence of a Mongolian spot, which is observed in races with dark skin tones.

The nurse is preparing a handout on the ovarian cycle to a group of middle school girls. Which information should the nurse include? 1. The hormone human chorionic gonadotropin stimulates ovulation. 2. Irregular menstrual cycles have varying lengths of the luteal phase. 3. The ovum travels from the ovary to the tube during the luteal phase. 4. There are two phases of the ovarian cycle: luteal and follicular.

Correct Answer: 4 Rationale 4: The two phases of the ovarian cycle are follicular (days 1-14 of the menstrual cycle) and luteal (days 15-28 of the menstrual cycle).

The postpartum nurse is mentoring a new graduate nurse. They are working with a Muslim family who had their first child yesterday. The new graduate asks the family what supplies they have at home. The husband responds that they have not yet purchased anything for their baby. How should the mentoring nurse explain this finding to the new graduate nurse? 1. This family is irresponsible, and should have acquired all the items they will need for the new baby prior to going into labor. 2. The woman did not communicate what her due date was to her husband because of cultural issues. 3. Income seems to be a problem for this family; social services should be contacted to assist the family. 4. Muslims don't buy baby items prior to birth because they believe it is God's will, not their own decision, whether a baby will live.

Correct Answer: 4 Rationale 4: This is a true statement. Understanding cultural variations on childbearing is important for a nurse to provide good care to patients.