Semester 3 Unit 5 exam

(med surg) To prevent capsular formation after breast reconstruction with implants, teach the patient to a. gently massage the area around the implant. b. bind the breasts tightly with elastic bandages. c. exercise the arm on the affected side to promote drainage. d. avoid strenuous exercise until the implant has healed.

a. gently massage the area around the implant

A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? "a. ""Have you noticed a change in sleeping habits recently?" " b. ""Have you had a respiratory infection in the last 6 months?" " c. ""Have you lost weight recently?" " d. ""Have you noticed changes in your alertness?"""

" b. ""Have you had a respiratory infection in the last 6 months?" The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

"What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? "A. potential for injury B. self-care deficit C. potential for self harm D. alteration in comfort"

"A. potential for injury Low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage.

"In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.)" A. Maintaining a clean technique for all invasive procedures. B. Placing the client in protective isolation. C. Limiting visitors who have colds and infections. D. Ensuring meticulous hand washing by all persons coming in contact with the client."

"Correct Answers: B, C, D Rationale: Chronic lymphoid leukemia (CLL) is characterized by a proliferation and accumulation of small, abnormal mature lymphocytes in bone marrow, peripheral blood, and body tissues. Infections and fever are frequent complications of CLL."

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?

10

A client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell count differential. 2. A large number of WBCs that decrease after the administration of antibiotics. 3. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level. 4. Red blood cells that are larger than normal.

1. A left shift in the white blood cell count differential. A left shift indicates immature white blood cells are being produced and released into the circulating blood volume. This should be investigated for the malignant process of leukemia."

Which are modes of heat loss in the newborn? Select all that apply. 1. Radiation 2. Urination 3. Convection 4. Conduction 5. Evaporation

1. Radiation 3. Convection 4. Conduction 5. Evaporation

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1. Determine Apgar score. 2. Auscultate the heart rate. 3. Thoroughly dry the newborn. 4. Take the newborn's rectal temperature.

3. Thoroughly dry the newborn.

4 yo is admitted for abdominal pain. She has been pale and excessively tired and is bruising easily. On physical exam, lymphadenopathy and hepatosplenomaegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. Which diagnostic study would confirm this diagnosis 1. Platelet count 2. Lumbar puncture 3. bone marrow biopsy 4. wbc count"

3. bone marrow biopsy leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test is microscopic exam of bone marrow obtained by bone marrow aspirate and biopsy. a lumbar puncture may be done to look for blast cells in the sc fluid that indicate CNS disease. The wbc count may be normal, high or low in leukemia an altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis"

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

3. Conduction

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket

The client diagnosed with leukemia has central nervous system involvement. Which instructions should the nurse teach? 1.Sleep with the head of the bed elevated to prevent increased intracranial pressure. 2.Take an analgesic medication for pain only when the pain becomes severe. 3.Explain that radiation therapy to the head may result in permanent hair loss. 4.Discuss end-of-life decisions prior to cognitive deterioration

3.Explain that radiation therapy to the head may result in permanent hair loss. 1.Sleeping with the head of the bed elevated might relieve some intracranial pressure, but it will not prevent intracranial pressure from occurring. 2.Analgesic medications for clients with cancer are given on a scheduled basis with a fast-acting analgesic administered PRN for break-through pain. 3.Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. If the radiation therapy destroys the hair follicle, the hair will not grow back. 4.Cognitive deterioration does not usually occur"

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? 1. Dry the newborn's head thoroughly. 2. Turn the thermostat in the room to 70°F. 3. Place the newborn near the nursery window. 4. Place a warm blanket on the examining table before placing the newborn on the table.

4. Place a warm blanket on the examining table before placing the newborn on the table.

A just delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism? 1. Radiation 3. Convection 4. Conduction 5. Evaporation

5. Evaporation

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/minute; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score?

9

A nurse in the fertility clinic is instructing a client who will be using progesterone gel vaginally in the treatment of luteal phase infertility. When discussing the side effects of progesterone, what should the nurse tell the client to expect? A. Enlarged, tender breasts B. Increased vaginal secretions C. Additional facial and body hair D. Decreased basal body temperature

A. Enlarged, tender breasts The hormonal influence of progesterone during the luteal phase of the menstrual cycle contributes to breast enlargement and tenderness. Vaginal secretions decrease, not increase, with the administration of progesterone. Loss of hair, not additional facial and body hair, is a side effect associated with the administration of progesterone. An increase, not decrease, in basal body temperature is associated with the administration of progesterone.

A client who is to undergo a mastectomy for breast cancer tells the nurse that she is worried about what she will look like after the surgery. What is the most appropriate initial response by the nurse? A. "I understand that you'd be concerned." B. "Try not to think about the surgery now." C. "Everyone having this surgery feels the same way." D. "Perhaps you should discuss this with your husband."

A. "I understand that you'd be concerned." Women facing breast surgery often have feelings relating to their sexuality and change in body image; the nurse plays a vital role in helping the client verbalize feelings, and this response keeps channels of communication open. The client's concerns are real, and a statement such as "Try not to think about the surgery now" will only block further communication. The response "Everyone having this surgery feels the same way" does not focus on the importance of the client as an individual; each person feels differently. The response "Perhaps you should discuss this with your husband" can be interpreted as the nurse's reluctance to listen; the client may not be able to talk with the husband about this.

A client in active labor is considering combined spinal-epidural analgesia. She states that she is concerned about her ability to walk after receiving this type of analgesia. What is the most accurate response by the nurse? A. "This analgesia gives you pain relief without compromising your ability to ambulate." B. "The analgesia will require you to remain in bed, but you'll be able to move from side to side." C. "You may experience slight weakness, but someone will be at your side when you're ambulating." D. "Someone will help you ambulate every couple of hours before you're given another dose of the analgesia."

A. "This analgesia gives you pain relief without compromising your ability to ambulate." Because the spinal nerve receptors are sensitive to opioids, small quantities are needed to produce analgesia; therefore the client's ability to ambulate without assistance is not jeopardized. Bed rest is not required. The analgesia does not cause weakness. The client's ability to ambulate without assistance is not jeopardized. The analgesia lasts for more than 2 hours; there is no need to ambulate before a dose is given.

After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate is prescribed. When will the nurse instruct the client to take clomiphene? A. Fifth day of her cycle B. Last day of her period C. Third day after her period begins D. Sixteenth day of her cycle

A. Fifth day of her cycle The objective is to stimulate ovulation near the fourteenth day of the menstrual cycle, and this is achieved by taking the medication on the fifth through the ninth days; there is an increase in two pituitary gonadotropins, luteinizing hormone and follicle-stimulating hormone, with subsequent ovarian stimulation. On the third day after the cycle there are insufficient hormones for clomiphene to be effective. The sixteenth day of the cycle is also too late for clomiphene to be effective.

A client with metastatic breast cancer is started on a multiple drug regimen that includes docetaxel. The nurse assesses the client for which nontherapeutic effects of docetaxel? Select all that apply. A. Alopecia B. Constipation C. Febrile neutropenia D. Increased blood pressure E. Hypersensitivity reaction

A. Alopecia C. Febrile neutropenia E. Hypersensitivity reaction Alopecia is a nontherapeutic response to docetaxel. Docetaxel affects interphase and mitosis of the cell cycle. Febrile neutropenia is a common nontherapeutic effect. Clients should concurrently receive a growth factor support agent such as pegfilgrastim when given a regimen of docetaxel. Hypersensitivity reactions (e.g., flushing, rash, local eruption) are common nontherapeutic reactions, particularly within the first few minutes of the infusion. Minor reactions do not require discontinuation of the therapy. Nausea, vomiting, and diarrhea, not constipation, are nontherapeutic effects of docetaxel. Hypotension, not hypertension, is a nontherapeutic effect of docetaxel.

A pregnant woman reports upper back pain and frequent and painful urination. Upon diagnosis, the client has a urinary tract infection and is treated with nitrofurantoin. Which teratogenic effect is likely to occur in the infant? A. Cleft palate B. Tooth anomalies C. Neural tube defects D. Ebstein anomaly

A. Cleft palate Nitrofurantoin may cause cleft palate in fetuses. The use of drug tetracyclines may cause tooth anomalies in fetuses. Ebstein anomaly may be caused by the use of the drug lithium. Neural tube defects may be caused by valproic acid.

The nurse is providing care to a multiparous client in active labor. The client is requesting something for the pain. What is the nurse's priority intervention? A. Examining the client's cervix for dilation and effacement B. Determining the client's options by assessing the prescriptions in the chart C. Asking her whether she prefers an epidural or something in her intravenous line D. Evaluating the fetal monitoring strip to determine the frequency and duration of contractions

A. Examining the client's cervix for dilation and effacement Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.

Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn? Select all that apply. A. Flexed fetal position B. Hepatic insulin stores C. Brown fat metabolism D. Peripheral vasoconstriction E.Parasympathetic nervous system

A. Flexed fetal position C. Brown fat metabolism D. Peripheral vasoconstriction Full-term neonates maintain a flexed fetal position, which conserves heat. Deposition of brown fat begins at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat, which releases heat as a by-product. Peripheral vasoconstriction helps conserve heat by keeping the central core warm and preventing heat from dissipating. Insulin is not stored in the liver and is not involved with maintenance of neonatal body temperature. The sympathetic, not parasympathetic, nervous system is involved in thermoregulation.

The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? A. Hemorrhage B. Dehydration C. Hypertension D. Subinvolution

A. Hemorrhage Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth

A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes does the nurse expect the parents to report? Select all that apply. A. Pale skin B. Loss of hair C. Eating less food D. Sores in the mouth E. Purplish spots on the skin

A. Pale skin C. Eating less food E. Purplish spots on the skin Pallor is a presenting sign of leukemia and reflects anemia because of decreased erythrocytes. Lack of appetite (anorexia) resulting in the consumption of less food is a presenting symptom of leukemia; it may be the result of enlarged lymph nodes and areas of inflammation in the intestinal tract. Decreased platelet production with petechiae and bleeding is a presenting sign of leukemia. Alopecia results from chemotherapy, not the leukemia. Sores in the mouth are not a presenting sign but often result from chemotherapy.

The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following?" A. Petechiae, fever, fatigue B. Headache, papilledema, irritability C. Muscle wasting, weight loss, fatigue D. Decreased intracranial pressure, psychosis, confusion

A. Petechiae, fever, fatigue

(powerpoints) Treatment goal for patient/couple with infertility issues. (select all that apply) A. Provide the couple with accurate information about human reproduction, infertility treatments, and prognosis for pregnancy B. Assist in identifying the cause of infertility C. Discuss the use of antidepressants D.Provide emotional support E. Guide and educate about forms of treatment

A. Provide the couple with accurate information about human reproduction, infertility treatments, and prognosis for pregnancy B. Assist in identifying the cause of infertility D.Provide emotional support E. Guide and educate about forms of treatment

"After a client with a potential diagnosis of leukemia is admitted to the hospital, the nurse should assess for which of the following? (Select all that apply.)" A. Reports of fatigue and weakness B. An elevation in the leukocytese specially neutrophils C. Signs of bruising easily D. Recent weight gain"

A. Reports of fatigue and weakness C. Signs of bruising easily Rationale: General manifestations of leukemia result from anemia, infection, and bleeding. The client would complain of fatigue and weakness and show signs of bruising. Leukemic cells replace normal hematopoietic elements preventing the formation of mature leukocytes. Neutrophil count would be decreased. Because of an increased metabolism, weight loss may occur.

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What early signs and symptoms of leukemia does the nurse expect to identify? Select all that apply. A. Flushing B. Anorexia C. Limb pain D. Splenomegaly E. Mouth lesions

B. Anorexia C. Limb pain D. Splenomegaly Hypermetabolism associated with the leukemic process results in loss of appetite. Bone marrow dysfunction and invasion of the periosteum result in bone pain. Infiltration, enlargement, and fibrosis of the spleen occur early in the disease process as the excess white blood cells are trapped. Flushing is not expected. Bone marrow dysfunction results in anemia, and pallor accompanies the decreased erythrocyte count. Mouth lesions (stomatitis) occur later during the disease process or as a result of chemotherapy.

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning? A. Shallow B. Blowing C. Slow chest D. Modified paced

B. Blowing Blowing forcefully through the mouth controls the strong urge to push and allows for a controlled birth of the head. A shallow breathing pattern does not help control expulsion of the fetus. Slow chest breathing is used during the latent phase of the first stage of labor; it is not helpful in overcoming the urge to push. Modified paced breathing is used during active labor when the cervix is dilated 3 to 7 cm; it is not helpful in overcoming the urge to push.

At 12 weeks' gestation a client with a history of several spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond? A. "I can understand why you're worried; however, you'll have other chances in the future to get pregnant." B. "You're getting the best of care. Please tell me about the problems with your previous pregnancies." C. "It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time." D. "Your pregnancy has lasted past the time when most early spontaneous abortions occur. I think you'll be able to continue the pregnancy."

C. "It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time." Affirming the validity of the client's concerns acknowledges her fearful feelings. It also permits further communication. Assuring the client that she will have other chances to get pregnant in the future does not acknowledge the client's feelings; it also instills fear by implying that the current pregnancy may not go to term, even though there is no evidence to indicate this. Asking the client to talk about the problems with her prior pregnancies does not acknowledge her feelings of fear and changes the focus of the conversation. Telling the client that she should be able to continue the pregnancy is false assurance and does not address the client's feelings.

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. Which nursing action will help relieve this discomfort? A. Positioning her on the left side B. Using effleurage on her abdomen C. Applying pressure against her sacrum D. Placing her in the semi-Fowler position

C. Applying pressure against her sacrum Counterpressure over the sacral area helps relieve the pain caused by the pressure of the fetal head in the posterior position. Although helpful for placental perfusion, positioning the client on her left side is not the best action for reducing pain caused by the pressure of the fetal head in the posterior position. Massaging the abdomen with the fingertips (effleurage) does not relieve the painful pressure in the lower back. The semi-Fowler position causes additional discomfort because the sacrum is inaccessible and counterpressure cannot be applied to the sacral area.

A client who underwent treatment for infertility gave birth to triplets. She often complained of breast pain during the infertility treatment. Which drug may have been administered to the client for infertility treatment? A. Estradiol B. Haloperidol C. Clomiphene D. Promethazine

C. Clomiphene Clomiphene is an ovarian stimulant that may cause multiple pregnancies. Breast pain is an adverse effect of clomiphene. Estradiol helps to reduce postmenopausal hot flashes. Haloperidol and promethazine are contraindicated while using clomiphene.

A woman who is infertile is diagnosed with primary ovarian failure. Which fertility drug regimen may be prescribed to treat infertility? A. Clomiphene B. Menotropins C. Estrogens and progestins D. Choriogonadotropin alfa

C. Estrogens and progestins Exogenous administration of estrogens or progestins is used to treat infertility associated with primary ovarian failure. The administration of clomiphene, menotropins, and choriogonadotropin alfa cannot stimulate the ovaries to increase the levels of estrogens or progestins.

Nursing considerations related to the administration of chemotherapeutic drugs include which of the following? A. Anaphylaxis cannot occur, since the drugs are considered toxic to normal cells. B. Infiltration will not occur unless superficial veins are used for the intravenous infusion. C. Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates. D. Good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary."

C. Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and be prepared to treat extravasations if necessary. 1. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents. 2. Infiltration and extravasations are always a risk, especially with peripheral veins. 4. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn? A. Naloxone (Narcan) B. Lorazepam (Ativan) C. Meperidine (Demerol) D. Promethazine (Phenergan)

C. Meperidine (Demerol) **Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth.

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? A. "I will leave the skin markings intact." B. "I will protect the skin from sources of heat." C. "I will wear soft clothing over the upper body." D. "I will use an oatmeal-based lotion after each treatment."

D. "I will use an oatmeal-based lotion after each treatment." While undergoing radiation therapy, lotions, powders, and ointments should not be applied to the area. The skin markings should not be removed, because they form the parameters for the delivery of radiation. To protect the irradiated skin, sunlight and heat should be avoided. Nonirritating clothing should be worn over the area to prevent trauma to the delicate irradiated skin.

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response? A. "Smoking marijuana is not legal in any state." B. "Marijuana is effective for nausea and vomiting if it is injected." C. "Marijuana is not proven to be effective in preventing chemotherapy-induced nausea and vomiting." D. "Tetrahydrocannabinol is an ingredient in marijuana that decreases nausea and vomiting in some people."

D. "Tetrahydrocannabinol is an ingredient in marijuana that decreases nausea and vomiting in some people." Tetrahydrocannabinol, an ingredient in marijuana, acts as an antiemetic in some persons and can be absorbed through the gastrointestinal tract or inhaled. The statement "Smoking marijuana is not legal in any state" does not answer the client's question and is inaccurate. Marijuana is not injected. Tetrahydrocannabinol, an ingredient in marijuana, is an effective antiemetic for some clients.

A nurse is teaching a childbirth preparation class. Which information regarding discomfort during labor should the nurse be certain to include in her teaching? A. Labor should be mostly pain free and uneventful. B. Breathing techniques will be taught to prevent the need for medication. C. Medication is given to women who experience painful labor contractions. D. Comfort measures are available when the discomfort of contractions becomes excessive.

D. Comfort measures are available when the discomfort of contractions becomes excessive. Classes in preparation for parenthood should help couples develop realistic expectations of the labor process, including associated discomfort and ways of dealing with it. Stating that labor should be mostly pain free and uneventful is false reassurance; contractions are uncomfortable, and there is no guarantee that the birthing process will be uneventful. Breathing techniques may not be enough for some women to limit the discomfort of contractions. The focus should not be on pain; comfort measures should be attempted first before medication is used.

A female client is undergoing treatment for infertility. After therapy with clomiphene the client comes for follow-up visits and no results are seen. What further treatment does the nurse anticipate administering? A. Estrogen B. Progesterone C. Human growth hormone D. Human chorionic gonadotropin

D. Human chorionic gonadotropin Clomiphene is used to induce pregnancy by triggering ovulation. If the desired result is not obtained, the second alternative is to administer human chorionic gonadotropin and gonadotropin-releasing hormone to stimulate ovulation. A combination of estrogen and progesterone is generally administered to treat female clients who have a gonadotropin deficiency. Human growth hormone injections are administered to treat adults with growth hormone deficiency.

The nurse is interviewing a 41-year-old woman who is being seen in the infertility clinic for her first visit. She and her husband have been married for 3 years and have not used any form of contraception during this time. Neither the woman nor her husband has children from previous relationships. She asks the nurse what test or treatment will be done first. What should the nurse inform her that she and her husband should expect? A. A laparoscopy B. The start of fertility medication C. A hysteroscopy D. Semen analysis

D. Semen analysis Semen analysis is painless, is less costly than other interventions, and provides important information regarding the male partner's fertility. Fertility medication would not be initiated until an evaluation of ovulatory function had been completed. Simpler evaluations and therapies are completed before more complex efforts such as surgical procedures like laparoscopy and hysteroscopy are performed.

A client with oat-cell lung cancer is scheduled for a mediastinoscopy and biopsy. What should the nurse include in the client's education? A. Chest tubes will be in place after the procedure. B. The procedure will visualize the mainstem bronchus. C. Some pleural fluid will be removed during the procedure. D. The procedure is an endoscopic examination of lymph nodes.

D. The procedure is an endoscopic examination of lymph nodes. A mediastinoscopy is an endoscopic examination of mediastinal lymph nodes through a small suprasternal incision; this generally is done to diagnose mediastinal involvement of pulmonary malignancy or other conditions. Chest tubes are not required unless the lungs are accidentally punctured. A bronchoscopy permits visualization of the mainstem bronchus. Fluid is removed from the pleural space during a thoracentesis.

While assessing a newborn, the nurse notes that the infant's skin is mottled. What should the nurse's primary intervention be? A. Administer oxygen B. Offer an oral feeding C. Notify the practitioner D. Warm the environment

D. Warm the environment Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.

(med surg) . When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is a. being a woman over age 60. b. experiencing menstruation for 30 years or more. c. using hormone therapy for 5 years for menopausal symptoms. d. having a paternal grandmother with postmenopausal breast cancer.

a. being a woman over age 60.

(med surg) When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is a. being a woman over age 60. b. experiencing menstruation for 30 years or more. c. using hormone therapy for 5 years for menopausal symptoms. d. having a paternal grandmother with postmenopausal breast cancer.

a. being a woman over age 60.

A bone marrow transplant is being considered for treatment of a patient with acute leukemia that has not responded to chemotherapy. In discussing the treatment with the patient, the nurse explains that a. hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT). b. the transplant of the donated cells is painful because of the nerves in the tissue lining the bone. c. donor bone marrow cells are transplanted immediately after an infusion of chemotherapy. d. the transplant procedure takes place in a sterile operating room to minimize the risk for infection."

a. hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT). The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room required. The HSCT takes place 1 or 2 days after chemotherapy to prevent damage to the transplanted cells by the chemotherapy drug."

(med surg) A patient with breast cancer has a lumpectomy with sentinel lymph node biopsy that is positive for cancer. You explain that, of the other tests done to determine the risk for cancer recurrence or spread, the results that support the more favorable prognosis are (select all that apply) a. well-differentiated tumor. b. estrogen receptor-positive tumor. c. overexpression of HER-2 cell marker. d. involvement of two to four axillary nodes. e. aneuploidy status from cell proliferation studies.

a. well-differentiated tumor. b. estrogen receptor-positive tumor.

(med surg) A patient with breast cancer has a lumpectomy with sentinel lymph node biopsy that is positive for cancer. You explain that, of the other tests done to determine the risk for cancer recurrence or spread, the results that support the more favorable prognosis are (select all that apply) a. well-differentiated tumor. b. estrogen receptor-positive tumor. c. overexpression of HER-2 cell marker. d. involvement of two to four axillary nodes. e. aneuploidy status from cell proliferation studies.

a. well-differentiated tumor. b. estrogen receptor-positive tumor.

(med surg) Preoperatively, to meet the psychologic needs of a woman scheduled for a simple mastectomy, you would a. discuss the limitations of breast reconstruction. b. include her significant other in all conversations. c. promote an environment for expression of feelings. d. explain the importance of regular follow-up screening

c. promote an environment for expression of feelings.

(med surg) Preoperatively, to meet the psychologic needs of a woman scheduled for a simple mastectomy, you would a. discuss the limitations of breast reconstruction. b. include her significant other in all conversations. c. promote an environment for expression of feelings. d. explain the importance of regular follow-up screening.

c. promote an environment for expression of feelings.

You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. To best promote the participants' learning and adherence, you would include (select all that apply) a. a short audiotape on the BSE procedure. b. a packet of articles from the medical literature. c. written guidelines for mammography and CBE. d. a discussion of the value of early breast cancer detection. e. community resources where they can obtain an ultrasound and MRI.

c. written guidelines for mammography and CBE. d. a discussion of the value of early breast cancer detection.

(med surg) You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. To best promote the participants' learning and adherence, you would include (select all that apply) a. a short audiotape on the BSE procedure. b. a packet of articles from the medical literature. c. written guidelines for mammography and CBE. d. a discussion of the value of early breast cancer detection.

c. written guidelines for mammography and CBE. d. a discussion of the value of early breast cancer detection.

(med surg) A simple mastectomy has been scheduled for your patient with breast cancer. Postoperatively, to restore arm function on the affected side, you would a. apply heating pads or blankets to increase circulation. b. place daily ice packs to minimize the risk of lymphedema. c. teach passive exercises with the affected arm in a dependent position. d. emphasize regular exercises for the affected shoulder to increase range of motion.

d. emphasize regular exercises for the affected shoulder to increase range of motion.

(med surg). A simple mastectomy has been scheduled for your patient with breast cancer. Postoperatively, to restore arm function on the affected side, you would a. apply heating pads or blaterm-118nkets to increase circulation. b. place daily ice packs to minimize the risk of lymphedema. c. teach passive exercises with the affected arm in a dependent position. d. emphasize regular exercises for the affected shoulder to increase range of motion.

d. emphasize regular exercises for the affected shoulder to increase range of motion.

(med surg) . You are caring for a young woman who has painful fibrocystic breast changes. Management of this patient would include a. scheduling a biopsy to rule out malignant changes. b. teaching that symptoms will probably subside if she stops using oral contraceptives. c. preparing her for surgical removal of the lumps, since they will become larger and more painful. d. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relieve some discomfort.

d. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relieve some discomfort.

(med surg) You are caring for a young woman who has painful fibrocystic breast changes. Management of this patient would include a. scheduling a biopsy to rule out malignant changes. b. teaching that symptoms will probably subside if she stops using oral contraceptives. c. preparing her for surgical removal of the lumps, since they will become larger and more painful. d. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relieve some discomfort.

d. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relieve some discomfort.

(med surg) In teaching a patient who wants to perform BSE, you inform her that the technique involves both the palpation of the breast tissue and a. palpation of cervical lymph nodes. b. hard squeezing of the breast tissue. c. a mammogram to evaluate breast tissue. d. inspection of the breasts for any changes.

d. inspection of the breasts for any changes.

(med surg) In teaching a patient who wants to perform BSE, you inform her that the technique involves both the palpation of the breast tissue and a. palpation of cervical lymph nodes. b. hard squeezing of the breast tissue. c. a mammogram to evaluate breast tissue. d. inspection of the breasts for any changes.

d. inspection of the breasts for any changes.

When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: a.Discourage the use of stool softeners b.Assess temperature readings every six hours c.Avoid invasive procedures d.Encourage the use of a hard, brittle toothbrush

d.Encourage the use of a hard, brittle toothbrush "Answer: CRationale:Thrombocytopenia is a deficiency of platelets, and leaves the patient more prone to hemmorrhage. For this reason, avoiding invasive procedures will limit the risk of hemorrhage. Stool softeners should be encouraged, while hard brittle toothbrushes should be avoided. Temperature is not the most important vital to track in this patient"

(power points) the nurse knows that placing the naked newborn on mom's bare chest and covering both with a blanket/towel does what

reduces conduction and radiation heat loss enhances newborn temperature control enhances maternal infant interaction

The nurse and the unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? A. Take the hourly vital signs on a client receiving blood transfusions. B. Monitor the infusion of antineoplastic medications. C. Transcribe the HCP's orders onto the Medication Administration Record. D. Determine the client's response to the therapy."

"A. Take the hourly vital signs on a client receiving blood transfusions. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse. B. Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. C. This is the responsibility of the word secretary or the nurse, not the unlicensed personnel. D. This represents the evaluation portion of the nursing process and cannot be delegated."

"The mother of a child diagnosed with a potentially life-threatening form of cancer says to the nurse, ""I don't understand how this could happen to us. We have been so careful to make sure our child is healthy."" Which response by the nurse is most appropriate? "A. Why do you say that? Do you think that you could have prevented this?" "B. ""This must be a difficult time for you and your family. Would you like to talk about how you are feeling?" "C. ""You shouldn't feel that you could have prevented the cancer. It is not your fault." "D.""Many children are diagnosed with cancer. It is not always life-threatening."""

"B. ""This must be a difficult time for you and your family. Would you like to talk about how you are feeling?" Parents of children diagnosed with cancer require major emotional support, and should be allowed to express their feelings. Prevention and blaming oneself is not supportive, nor is telling the parents that there are many other children with cancer."

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine? 1. The newborn requires vigorous resuscitation. 2. The newborn is adjusting well to extrauterine life. 3. The newborn requires some resuscitative interventions. 4. The newborn is having some difficulty adjusting to extrauterine life

3. The newborn requires some resuscitative interventions

A client with a history of three spontaneous abortions is now at 16 weeks' gestation and attending the high-risk prenatal clinic. She expresses concerns about remaining at home during this pregnancy. Which questions will elicit responses most helpful to the nurse developing the client's plan of care? Select all that apply. A. "Do you have a support system available to help you?" B. "Have you been told about the status of your pregnancy?" C. "Do you know the causes related to spontaneous abortions?" D. "Are you aware of how a healthy lifestyle affects a pregnancy?" E. "What are the characteristics of an impending spontaneous abortion?"

A. "Do you have a support system available to help you?" B. "Have you been told about the status of your pregnancy?" The availability of support persons is important when the client is deciding how to try to maintain the pregnancy. Knowing the status of her pregnancy is helpful to the nurse planning her care. If the status is not known, the nurse can correct any misconceptions and assist the client in focusing on reality while helping ease her anxiety. The causes of spontaneous abortion are not always known; theoretic knowledge of the causes will not help the client maintain her pregnancy. Questions about the interrelationship of lifestyle and a healthy pregnancy may add to the client's anxiety; they are not relevant at this time. Questioning the client's knowledge of an impending spontaneous abortion may add to the client's anxiety; after three abortions the client probably knows what to expect before a spontaneous abortion.

The nurse is caring for a couple during their initial visit to a fertility clinic after being unable to conceive for 2 years. Which of the following assessment questions would be appropriate to determine an alternate cause of infertility? A. "Do you use any lubrication during intercourse?" B. "Can both of you reach orgasm at the same time?" C. "What type of birth control did you use in the past?" D. "Are you consistent in the manner in which you have intercourse?

A. "Do you use any lubrication during intercourse?" Some lubricants act as a spermicide; they should be avoided, or only a recommended one should be used. A female orgasm is not necessary for conception; simultaneous orgasms is not a relevant question. The type of birth control before the couple began trying to conceive 2 years ago is not relevant at this time; some hormonal contraceptives should be discontinued 6 to 18 months before trying to conceive. Consistency in the manner of intercourse usually is not relevant to conception, although a change in position may be recommended

A pregnant client who has type 2 diabetes and a history of three spontaneous abortions is scheduled for a contraction stress test. Before the test she begins to cry while answering the nurse's questions regarding her previous pregnancies. She states, "I know it's my diabetes. This baby will never live. It's all my fault." What is the best response by the nurse? A. "This must be very stressful for you." B. "Diabetes is a difficult disease to manage during pregnancy." C. "This baby will live because it is being very closely monitored." D. "I know you're worried, but getting upset can alter your test results.

A. "This must be very stressful for you." By acknowledging the situation is stressful for the client, the nurse empathizes with the client and keeps the lines of communication open without being judgmental. Stating that diabetes is a difficult disease to manage during pregnancy does not address the client's feelings and may increase the client's anxiety. Stating that the baby will live constitutes false reassurance; close monitoring does not guarantee a live baby. Stating that getting upset can alter test findings denies the client's right to emotions and may evoke more feelings of guilt about her obstetric history.

Which physiologic characteristics of newborns affect drug dosage considerations? Select all that apply. A. A newborn's less regulated body temperature B. Immature liver and kidneys C. Thick and less permeable skin D. Lungs with weaker mucous barriers E. Bacteria-killing acid in the stomach

A. A newborn's less regulated body temperature B. Immature liver and kidneys D. Lungs with weaker mucous barriers The body temperature of newborns is less regulated and dehydration occurs easily. This characteristic affects the drug dose consideration in newborns. Metabolism and excretion are impaired in pediatric clients due to an immature liver and kidneys. The lungs in pediatric clients have weak mucous barriers; this characteristic also affects the drug dosage considerations in newborns. A newborn's skin is thin and more permeable. The newborn has no acid in the stomach to kill the bacteria; therefore, drug absorption from the gastrointestinal tract is affected, thus impacting drug dosage considerations.

After a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis Uncorrected cold stress increases anaerobic glycolysis, which increases acid production, resulting in metabolic acidosis. Metabolic acidosis, not metabolic alkalosis, occurs when a neonate is stressed by cold. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory acidosis, occurs. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory alkalosis, occurs.

Nurse is caring for a client in preterm labor who is receiving a course of corticosteroids to promote fetal lung maturity. What test may be used to most accurately determine fetal lung maturity? A. Amniocentesis B. Ultrasonography C. Radioreceptor assay D. Chorionic villus sampling

A. Amniocentesis The presence of phosphatidylglycerol and a 2:1 lecithin/sphingomyelin ratio in the amniotic fluid confirm fetal lung maturity. Ultrasonography cannot be used to determine fetal lung maturity. The radioreceptor assay is a test used to determine whether the client is pregnant; it is done very early in pregnancy. Chorionic villus sampling, a diagnostic screening test, is done between the eighth and twelfth weeks of pregnancy to determine fetal chromosomal status.

A client who is suspected of having leukemia has a bone marrow aspiration. What should the nurse do Immediately after the procedure? A. Apply brief pressure to the site. B. Have the client lie on the affected side. C. Swab the site with an antiseptic solution. D. Monitor vital signs every hour for 4 hours.

A. Apply brief pressure to the site. Brief pressure is generally enough to prevent bleeding at the aspiration site. Complications are rare; no special positions are required. The site is cleaned before aspiration. Frequent monitoring is unnecessary.

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include? A. Assessing respirations, keeping him warm, and identifying him B. Applying an antibiotic to the eyes, administering vitamin K, and bathing him C. Aspirating the oropharynx, rushing him to the nursery, and stimulating him often D. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

A. Assessing respirations, keeping him warm, and identifying him Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

Which drug does the nurse anticipate to be prescribed to a client seeking treatment for infertility? A. Clomiphene B. Misoprostol C. Dinoprostone D. Methylergonovine

A. Clomiphene Clomiphene causes the maturation of ovarian follicles, which leads to ovulation. This drug is used to promote fertility. Misoprostol and dinoprostone are prostaglandins that cause uterine muscle contractions. Methylergonovine is an ergot alkaloid used to reduce postpartum uterine hemorrhage.

A client and her partner are working together to achieve an unmedicated birth. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that will alleviate the client's discomfort during contractions? A. Deep-breathe slowly. B. Perform pelvic rocking. C. Use the panting technique. D. Begin patterned, paced breathing.

A. Deep-breathe slowly. Slow, deep breathing expands the spaces between the ribs and raises the abdominal muscles, giving the uterus room to expand and preventing painful pressure of the uterus against the abdominal wall. Pelvic rocking is used to relieve pressure from back labor. Panting is used to halt or delay the expulsion of the infant's head before complete dilation has occurred. Patterned, paced breathing is used during the transition phase of the first stage; the client has not yet reached this phase.

(powerpoint) How is pain classified (select all that apply) A. Duration B. Characteristics C. Etiology D. Source/location

A. Duration ( acute or chronic) C. Etiology (nociceptive or neuropathic) D.Source/location (somatic or visceral)

The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? A. Fever and infections B. Nausea and vomiting C. Excessive energy and high platelet counts. D. Cervical lymph node enlargement and positive acid-fast bacillus.

A. Fever and infections Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce WBCs of the number and maturity needed to fight infection (CORRECT). 2. Nausea and vomiting are symptoms related to the treatment of cancer but not to the diagnosis of leukemia (omit #2). 3. The clients are frequently fatigued and have low platelet counts. The platelet count is low as a result of the inability of the bone marrow to produce the needed cells (omit #3). 4. Cervical lymph node enlargement is associated with Hodgkin's lymphoma, and positive acid-fast bacillus is diagnostic for tuberculosis (omit #4)."

A woman has been administered clomiphene as part of a treatment for infertility. What assessments indicate that the drug is working effectively? Select all that apply. A. Increased estrogens B. Increased ovarian stimulation C. Increased luteinizing hormone D. Decreased follicle-stimulating hormone E. Decreased gonadotropin-releasing hormone

A. Increased estrogens B. Increased ovarian stimulation C. Increased luteinizing hormone Clomiphene acts by stimulating the hypothalamus in the treatment for infertility. This drug indirectly increases the levels of estrogens, which causes ovarian stimulation due to the increase in the levels of luteinizing hormone. Stimulation of the hypothalamus by clomiphene indirectly increases the level of follicle-stimulating hormone via the increased production of gonadotropin-releasing hormone from the hypothalamus

A woman reports irregular menses and weight gain. Upon diagnosis, the woman has low hormone levels and is treated with infertility drugs to conceive. Which nursing interventions would be beneficial to this client? Select all that apply. A. Monitor vital signs. B. Encourage the client to track her medications in a journal. C. Recommend the self-administration of oral drugs. D. Recommend the long-term use of indomethacin orally. E. Administer oral drugs to the client when the client wakes up along with six glasses of water.

A. Monitor vital signs. B. Encourage the client to track her medications in a journal. C. Recommend the self-administration of oral drugs. The nurse should monitor the client's vital signs to minimize the risk of hypotension. Journal tracking of medication helps to ensure the regular administration of the drug. Self-administration of oral drugs at home should be encouraged, and proper instructions regarding the administration should be provided to ensure rational use of the drug. The nurse should not advise the long-term oral use of indomethacin because it may cause birth defects. The administration of oral drugs upon rising with six glasses of water is the nursing intervention for administration of oral bisphosphonates in the treatment of osteoporosis.

A patient has come to the healthcare clinic complaining of pain in his left arm after an injury. Which describes the characteristics of nociceptive pain? Select all that apply. A. Nociceptive pain may be localized to the area of injury B. Nociceptive pain develops after an injury to the central nervous system C. Nociceptive pain is categorized as being either somatic or visceral pain D. Nociceptive pain is typically causes an increase in sympathetic activiety E. Nociceptive pain can be referred pain

A. Nociceptive pain may be localized to the area of injury C. Nociceptive pain is categorized as being either somatic or visceral pain E. Nociceptive pain can be referred pain Rationale: Nociceptive pain describes a type of pain that occurs when there is damage to body tissue. A patient may experience this type of pain with a physical injury, such as a fracture or laceration. It is further categorized as being somatic or visceral pain and it can be referred from its original location and felt in another area of the body.

The nurse is reevaluating a newborn who had an axillary temperature of 97° F (36.1° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36.1° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? A. Placing the newborn under a radiant warmer in the nursery B. Checking the newborn for a wet diaper and then continue the skin-to-skin contact C. Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour D. Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

A. Placing the newborn under a radiant warmer in the nursery The newborn's temperature should be kept in the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C). A hypothermic temperature that has not improved in 1 hour with the use of skin-to-skin contact requires additional measures. The infant should be placed under a radiant warmer for a short time until the temperature returns to the normal range. Continuing skin-to-skin contact would not resolve the problem of hypothermia. Double-wrapping the newborn in warm blankets and leaving the newborn at the bedside would not be an adequate means of resolving the hypothermia.

A tocolytic was administered to a woman to inhibit labor and maintain pregnancy. Which nursing interventions would be beneficial to this client? Select all that apply. A. The drug should not be administered on a long term basis. B. The drug should be continued after the contractions subside. C. The client's vital signs and fetal heart rate should be monitored regularly. D. The dose and route of administration should be determined. E. The client should be placed in the right lateral recumbent position.

A. The drug should not be administered on a long term basis. C. The client's vital signs and fetal heart rate should be monitored regularly. D. The dose and route of administration should be determined. Long-term use of tocolytics may cause birth defects; therefore, tocolytics should not be administered on a long-term basis. The vital signs and fetal heart rate should be monitored regularly and closely to detect any abnormalities. The dose and route of administration should be determined to avoid inaccurate dosing. The drug should be discontinued after contractions cease. The client should be placed in the left lateral recumbent position to increase blood flow to the fetus and to increase renal blood flow.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. A. The nurse keeps the newborn covered in warm blankets. B. The nurse keeps the newborn under the radiant warmer. C. The nurse places the newborn on the mother's abdomen. D. The nurse measures the newborn's temperature regularly. E. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

A. The nurse keeps the newborn covered in warm blankets. B. The nurse keeps the newborn under the radiant warmer. C. The nurse places the newborn on the mother's abdomen. Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

A primigravida at 34 weeks' gestation tells the nurse that she is beginning to experience some lower back pain. What should the nurse recommend that the client do? Select all that apply. A. Wear low-heeled shoes. B. Wear a maternity girdle during waking hours. C. Sleep flat on her back with her feet elevated. D. Perform pelvic tilt exercises several times a day. E. Take an ibuprofen (Motrin) tablet at the onset of back pain.

A. Wear low-heeled shoes. D. Perform pelvic tilt exercises several times a day. Low-heeled shoes help maintain her center of gravity to counterbalance the gravid uterus. Pelvic tilt exercises help relieve lower backaches, are easily learned, and can be done without any equipment. A maternity girdle is not routinely recommended. Sleeping flat during this stage of pregnancy decreases venous return, impedes respiration, and puts pressure on the vena cava, which can cause uteroplacental insufficiency. Nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin) should be avoided during pregnancy, and the prescription of medications is beyond the scope of nursing practice.

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy, and crackles can be felt. How does the nurse describe this assessment finding? A. Stridor B. Crepitus C. Pitting edema D. Chest distention

B. Crepitus There is air in the tissues, and palpation results in a crackling sound referred to as crepitus. Stridor is a harsh, high-pitched sound usually produced on inspiration because of airway obstruction. Pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.

Which medication is indicated for evacuation in case of a miscarriage? A. Clomiphene B. Dinoprostone C. Magnesium sulfate D. Methylergonovine

B. Dinoprostone Dinoprostone is a prostaglandin E 2 abortifacient and cervical ripening drug, which is indicated for uterine evacuation in cases of miscarriage. Clomiphene is indicated for female infertility in some clients. Magnesium sulfate is used to treat pregnancy-induced hypertension. Methylergonovine is used to treat postpartum uterine atony and hemorrhage.

A nurse is performing an assessment on a fifth-grader who has been admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What early clinical findings does the nurse expect to identify? A. Nosebleeds and papilledema B. Fatigue and ecchymotic areas C. Abdominal pain and reddened complexion D. Enlargement of the axillary and groin lymph nodes

B. Fatigue and ecchymotic areas Fatigue and ecchymoses are early clinical findings to ALL. They are caused by decreased white blood cell, red blood cell (RBC), and platelet production that results when the bone marrow is crowded with abnormal lymph cells. Although epistaxis does occur, papilledema is not a common presenting sign because the blood-brain barrier is an initial deterrent. Pain is not an early symptom of ALL. The skin will be pale, not reddened, because of a decreased RBC count. Enlargement of lymph nodes in the axillae and groin is a sign of lymphoma or a late, not early, sign of leukemia.

A laboratory report shows that a client tested positive for human epidermal growth factor (HER), and a medical report reveals the presence of advanced breast cancer. Which medication would be used to treat this condition? A. Erlotinib B. Lapatinib C. Rituximab D. Tositumomab

B. Lapatinib HER-2 is overexpressed in clients with advanced breast cancer. Lapatinib inhibits epidermal growth factor-r (EGFR)-tyrosine kinase (TK) and binds HER-2. Erlotinib is an EFGR-TK inhibitor prescribed to treat non-small cell lung cancer and advanced pancreatic cancer. Rituximab and tositumomab are administered to treat non-Hodgkin's lymphoma.

A nurse is reviewing the health history and laboratory results of a school-aged child admitted to the pediatric unit with acute nonlymphoid leukemia (acute myeloid leukemia). What clinical findings does the nurse expect? Select all that apply. A. Oliguria B. Listlessness C. Few stem cells D. Difficulty swallowing E. Bone marrow depression

B. Listlessness E. Bone marrow depression Listlessness in a child with leukemia is caused by anemia; anemia is expected in children with leukemia because of generalized bone marrow depression. Depressed bone marrow production of formed elements of blood is characteristic of nonlymphoid leukemia; it leads to neutropenia and increases susceptibility to infection. Urine output will be within expected limits; there is no kidney involvement at this stage of the disease. There are more, not fewer, stem cells in the peripheral blood and bone marrow; the production of mature blood cells is depressed. The swallowing reflex is not affected.

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply. A. Nausea B. Melena C. Purpura D. Diarrhea E. Hematuria

B. Melena C. Purpura E. Hematuria Black, tarry feces caused by the action of intestinal secretions on blood are associated with bleeding in the gastrointestinal tract; bleeding is related to a reduced number of thrombocytes, which are part of the coagulation process. Hemorrhages into the skin and mucous membranes (purpura) may occur with reduced numbers of thrombocytes, which are part of the coagulation process. Blood in the urine (hematuria) may occur with a reduced number of thrombocytes, which are part of the coagulation process. Nausea and vomiting are not related to thrombocytopenia; they occur because of the effect of chemotherapy on the rapidly dividing cells of the mucous membranes of the gastrointestinal system. Diarrhea may be a side effect of chemotherapy, but it is not a thrombocytopenic side effect.

Which drug is used to prevent preterm labor? A. Oxytocin B. Nifedipine C. Raloxifene D. Clomiphene

B. Nifedipine Nifedipine is used to prevent preterm labor because it inhibits myometrial activity by blocking the influx of calcium. Oxytocin may be used to induce labor. Raloxifene is used to prevent postmenopausal osteoporosis. Clomiphene is used to cause ovulation.

Hysterosalpingography (HSG) is performed to determine whether a client has a tubal obstruction. The nurse explains to the client that infertility caused by a defect in the tube is most often related to what? A. A tubal injury B. Past infection C. A fibroid tumor D. A congenital anomaly

B. Past infection Past pelvic infections may result in tubal occlusions, most of which are caused by postinfection adhesions. Although tubal injury is possible, tubal infections are more common. Fibroid tumor is a benign tumor of the uterus and does not affect the tube. Tubal congenital anomalies are rare; uterine anomalies are more common.

The client is unable to become pregnant after she has had one full-term pregnancy. The nurse should develop a plan of care for which health problem? A. Primary infertility B. Secondary infertility C. Unexplained infertility D. Combined factor infertility

B. Secondary infertility Rationale: Secondary infertility is the term for couples that have had one pregnancy but are unable to conceive again. Primary infertility describes the inabilityto conceive even once. Unexplained and combined factorinfertility are not terms used when discussing fertility.

The nurse is caring for a client in the first stage of labor. Which position is the least desirable for the client if she is experiencing lower back pain? A. Sitting B. Supine C. Knee-chest D. Left side-lying

B. Supine Low back pain is aggravated when the client is in the supine position because of increased pressure from the fetus as the head rotates. A sitting position relieves back pain. The knee-chest position is an alternate position that a client may choose to use when laboring. The left side-lying position relieves back pain.

A pregnant woman reports severe headaches, chest pain, and fatigue. Upon diagnosis, the woman has hypertension. Which drug can be prescribed to reduce hypertension? A. Lithium B. Miglitol C. Calcium gluconate D. Magnesium sulfate

D. Magnesium sulfate Magnesium sulfate can be prescribed for pregnancy-induced hypertension. Lithium is used to treat body water retention. Miglitol is used to decrease blood sugar levels. Calcium gluconate is used to relieve magnesium toxicity associated with magnesium sulfate.

Which statements relate to preterm labor? Select all that apply. A. A premature baby has good cognitive development. B. The treatment for preterm labor includes bed rest and hydration. C. Preterm labor before the 20th week is indicative of a nonviable fetus. D. It is not desirable to stop the delivery in the case of preterm labor. E. Preterm labor refers to uterine contractions progressing to delivery before the 27th week of pregnancy.

B. The treatment for preterm labor includes bed rest and hydration. C. Preterm labor before the 20th week is indicative of a nonviable fetus. D. It is not desirable to stop the delivery in the case of preterm labor. E. Preterm labor refers to uterine contractions progressing to delivery before the 27th week of pregnancy. Bed rest and hydration are nonpharmacological interventions for treating preterm labor. Early labor pains before 20th week are indicative of a nonviable fetus and should generally be uninterrupted. A preterm labor may result in neonatal death, so pregnancy should be maintained to prevent neonatal death. The substantial uterine contractions before the 37th week of gestation leads to preterm labor. Preterm labor has significant poorer cognitive effects on premature babies.

A client who has been pregnant for 5 months experiences a spontaneous abortion after an accident. The client tells the nurse that she feels depressed over the loss of her son. She describes how he would have looked and how bright he would have been. What is the client demonstrating? A. Panic level of anxiety B. Typical grief syndrome C. Pathological grief reaction D. Diminished ability to test reality

B. Typical grief syndrome The client is grieving the loss of a fantasized child; talking about it is part of the typical grief reaction. The client is sad, not out of control or immobilized. The client is coping with the loss effectively. The client recognizes the loss, but is lamenting what could have been.

pregnancy in which the fetus has died in utero but products of conception are retained in utero for several weeks and there is a delay in expelling the fetus is known as what type of miscarriage? A. threatened B. missed C. inevitable D. complete

B. missed

"After a client is admitted to the pediatric unit with a diagnosis of acute lymphocytic leukemia, the laboratory test indicates that the client is neutropenic. The nurse should perform which of the following?" "A. advise the client to rest and avoid exertion B. prevent client exposure to infections C. monitor the blood pressure frequently D. observe for increased bruising"

B. prevent client exposure to infections Neutropenia is a decreased number of neutrophil cells in the blood which are responsible for the body's defense against infection. Rest and avoid exertion would be related to erythrocytes and oxygen carrying properties. Monitoring the blood pressure, and observing for bruising would be related to platelets and sign and symptoms of bleeding. Objective:

The partner of a primigravida who has been in active labor for about 6 hours asks the nurse, "How much longer will this take? She's having a lot of back pain, and she's so uncomfortable." How should the nurse respond? A. "It shouldn't be much longer now." B. "Take a short break while I take over." C. "Let me show you how to apply back pressure." D. "Everything is progressing nicely, just as expected."

C. "Let me show you how to apply back pressure." Counterpressure against the sacrum during contractions affords some relief from the discomfort of back pain. It is difficult to predict the duration of labor for any client. Telling the coach to leave is not a response to the situation; the coach should be included in providing comfort to the client. Telling the client that everything is progressing nicely is false reassurance; the data do not indicate that labor is progressing as expected.

The parents of a school-aged child with leukemia ask the nurse why irradiation of the spine and skull is necessary. What is the most accurate response by the nurse? A. "Radiation retards the growth of cells in the bone marrow of the cranium." B. "This therapy decreases cerebral edema and prevents increased intracranial pressure." C. "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain." D. "Neoplastic drug therapy without radiation is effective in most cases, but this is a precautionary treatment."

C. "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain." The protective blood-brain barrier initially screens leukemic cells from the central nervous system. However, in advanced stages leukemic infiltration occurs. Chemotherapeutic agents, also screened out by the blood-brain barrier, are ineffective. Radiation destroys, not just retards, malignant cells. Radiation does not decrease cerebral edema. Irradiation of the cranium is needed because chemotherapy does not pass the blood-brain barrier.

Which statement by a client being treated for infertility indicates the need for additional teaching? A. "I should come back for a postcoital test 1-2 days before I expect to ovulate." B. "I should schedule my hysterosalpingogram for the week after ovulation." C. "We should abstain for 14 days prior to coming back for the sperm penetration test." D. "I should schedule my endometrial biopsy for the last week of my menstrual cycle."

C. "We should abstain for 14 days prior to coming back for the sperm penetration test." The sperm penetration test, which tests for the ability of sperm to penetrate an egg, should be performed after 2-7 days of abstinence. Having a post-coital test before ovulation is not useful. A hypersalpingogram would be scheduled in the proliferative phase before ovulation to avoid early pregnancy or secretory changes in endometrium after ovulation, which could obstruct dyepassage. Endometrial biopsy should not be scheduled earlier than 10 to 12 days after ovulation to accurately detect effects of progesterone and endometrial sensitivity.

A pregnant client has labor pains. However, the nurse finds that the client's cervix is not dilated. Which drug should be administered to the client to promote labor? A. Oxytocin B. Nifedipine C. Dinoprostone D. Methylergonovine

C. Dinoprostone Dinoprostone induces cervical ripening. This action helps in the induction of labor at term. Oxytocin enhances labor when uterine contractions are weak and ineffective. Nifedipine is a calcium channel blocker used to maintain pregnancy during preterm labor. Methylergonovine reduces postpartum hemorrhage.

A client who has just experienced her second spontaneous abortion expresses anger toward the practitioner, the hospital, and the "rotten nursing care." When assessing the situation, the nurse concludes that the client may be using which coping mechanism? A. Denial B. Projection C. Displacement D. Reaction formation

C. Displacement The client's anger about the miscarriage is shifted to the staff and the hospital because she is unable to cope with her loss at this time. The client is neither ignoring nor refusing to recognize reality. The client is not attributing unacceptable or undesirable thoughts or feelings to another; nor is she exhibiting a behavior pattern opposite to what she feels.

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. How should the nurse interpret these findings? A. Unusual, indicating mental illness B. Normal, and no follow-up is required C. Expected, but needs to be addressed D. Serious, needing immediate acute care

C. Expected, but needs to be addressed Depression is an expected part of grieving that requires supportive care. Although depression is a normal response, intervention is necessary because it cannot be assumed that the depression will be of short duration. Depression is an expected response to the diagnosis of cancer; it does not indicate mental illness. Unless the client is suicidal, immediate acute care is not indicated.

A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history? A. G4 T3 P2 A1 L4 B. G5 T2 P2 A1 L4 C. G5 T2 P1 A1 L4 D. G4 T3 P1 A1 L4

C. G5 T2 P1 A1 L4 The acronym GTPAL represents gravidity, term births, preterm births, abortions, and living children; G5 T2 P1 A1 L4 indicates that the client has had five pregnancies (twins count as one pregnancy and the current pregnancy counts as one); two term births; one preterm birth (the twins); one abortion; and four living children. G4 T3 P2 A1 L4 indicates that there were four, not five, pregnancies; three, not two, term births; twins counted as one, not two, preterm birth; one abortion; and four living children. G5 T2 P2 A1 L4 indicates that there were five pregnancies; two term births; twins counted as one, not two, preterm births; one abortion; and four living children. G4 T3 P1 A1 L4 indicates that there were four, not five, pregnancies; three, not two, term births; twins counted as one preterm birth; one abortion; and four living children.

On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. What would the nurse determine that these laboratory results may be related to? A. Lymphadenopathy B. Thrombocytopenia C. Hypermetabolic status D. Hepatic encephalopathy

C. Hypermetabolic status The hypermetabolic state associated with leukemia causes more urea and uric acid (end products of metabolism) to be produced and to accumulate in the blood. Enlarged lymph nodes will not increase blood urea and uric acid. Thrombocytopenia causes a decrease in platelets, which causes bleeding. Hepatic encephalopathy is associated with liver disease, not leukemia.

A nurse is caring for a school-aged child with acute lymphoid leukemia. While examining the child's laboratory results, the nurse notes that the child is neutropenic. What does the nurse recognize as the cause of the neutropenia? A. Internal bleeding B. Overwhelming infection C. Increased immature cell growth D. Decreased intake of iron-rich nutrients

C. Increased immature cell growth Extensive growth of lymphoblasts suppresses the usual growth of red cells, white cells, and platelets. Internal bleeding does not cause neutropenia. Infection is a result, not the cause, of leukopenia. An iron-intake deficit will not result in neutropenia.

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear? A. Maternity girdle B. Support stockings C. Low-heeled shoes D. Loose-fitting clothing

C. Low-heeled shoes Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area. Maternity girdles are no longer recommended. Support stockings may be helpful for a woman with varicose veins or ankle edema; however, wearing them does not prevent back pain. Loose-fitting clothing is more comfortable, but has no effect on back pain.

A client undergoes a cesarean birth because of cephalopelvic disproportion. What care is needed for this client in addition to the routine nursing care given to all postpartum clients during the first 24 hours? A. Encouraging early ambulation B. Assessing the fundus gently but firmly C. Checking vital signs for evidence of shock D. Administering the prescribed pain medication

D. Administering the prescribed pain medication Because of increased pain and increased flatus, clients who have had cesarean births require more pain medication than do women who have vaginal births. Early ambulation is encouraged for all postpartum clients. Although this may be difficult because of the incision, palpating the fundus is a necessary part of postpartum care. Vital signs are checked routinely in all postpartum clients.

A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. Which is a priority nursing action? A. Tell the client that chest tubes will be present after the procedure. B. Explain that the procedure will allow visualization of lungs and chest cavity. C. Inform the client that some pleural fluid will be removed during this procedure. D. Advise the client to avoid eating or drinking anything for several hours before the test.

D. Advise the client to avoid eating or drinking anything for several hours before the test. To prevent aspiration during the procedure, clients are required to be nothing by mouth before the procedure. Chest tubes are not required unless the lungs are punctured accidentally. A mediastinoscopy permits visualization of the anterior mediastinum or hilum extrapleurally; bronchoscopy permits visualization of the larynx, trachea, and bronchi. Fluid is removed from the pleural space during a thoracentesis.

A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine is prescribed. How does this medication relieve pain? A. By producing amnesia B. By acting as a preliminary anesthetic C. By inducing sleep until the time of birth D. By acting on opioid receptors to reduce pain

D. By acting on opioid receptors to reduce pain Nalbuphine is classified as an opioid analgesic and is effective in relieving pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce amnesia, act as an anesthetic, or induce sleep.

Ten minutes after administering nalbuphine via intravenous piggyback to a primigravida in active labor, the nurse notes a fetal heart rate of 132 with minimal variability. The client states that the pain is more tolerable and she is able to use her breathing techniques more effectively. Contractions continue every 2 to 3 minutes and are of 60 seconds' duration. What is the nurse's next action? A. Reposition the client on the left side to increase placental perfusion. B. Administer oxygen via mask to minimize apparent fetal compromise. C. Have an opioid antagonist available to be administered to the infant at the time of birth. D. Document the findings, including the stable fetal heart rate variability after administering the opioid infusion.

D. Document the findings, including the stable fetal heart rate variability after administering the opioid infusion. A common side effect of an opioid analgesic is decreased fetal heart rate variability. Because the fetal heart rate and the length and duration of the contractions remain stable and the analgesic appears to be effective, the only nursing action is to document the findings. Repositioning the client is not necessary because the data do not indicate decreased placental perfusion. It is not necessary to administer oxygen because the data do not indicate fetal compromise. Naloxone, an opioid antagonist, may need to be administered to the newborn, but the present data do not indicate that this is necessary.

The nurse is caring for a client who has had a spontaneous abortion. The client asks why spontaneous abortions occur. The nurse responds that they are most commonly caused by what? A. Physical trauma B. Unresolved stress C. Congenital defects D. Embryonic defects

D. Embryonic defects Approximately 75% of all spontaneous abortions take place between 8 and 12 weeks' gestation and reveal embryonic defects. Though possible, physical trauma rarely causes an abortion. Unresolved stress is rarely associated with spontaneous abortions. Congenital defects are asymptomatic during pregnancy and do not usually cause abortion.

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? A.Radiation B.Convection C. Conduction D. Evaporation

D. Evaporation Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.

The parents of a child who is undergoing chemotherapy for acute lymphocytic leukemia (ALL) ask the nurse about the prognosis of children with this diagnosis. What does the nurse respond is the expected outcome for children with this type of leukemia? A. Guarded, but the therapy keeps them pain-free B. Limited to a few months in most of the children affected C. Positive, with probable cure in 95% of the children affected D. Extended to at least 5 years in more than 75% of the children treated

D. Extended to at least 5 years in more than 75% of the children treated Five-year disease-free survival rates for children with ALL are currently 75% to 85%. The long-term prognosis of a 95% cure rate is too favorable, although this is the percentage of children who achieve the first remission. The other projected prognoses (guarded, limited to a few months) are too pessimistic

Which nursing assessment is important to recognize to determine the causative factors in a client with a history of spontaneous abortions? A. Use of sex hormones B. Use of contraceptive pills C. Presence of heart problems D. History of alcohol consumption

D. History of alcohol consumption Alcohol consumption during pregnancy may cause fetal abnormalities and increase the risk of spontaneous abortions. The presence of heart problems may not cause spontaneous abortions. The use of sex hormones in pregnancy may cause fetal abnormalities. Contraceptive pills may inhibit the ovulation process, but they rarely affect the embryo.

What is the focus of nursing care for a newborn with respiratory distress syndrome (RDS)? A. Tapping the toes to stimulate respirations B. Turning the infant frequently to prevent apnea C. Maintaining oxygen concentration at 40% to support respiration D. Keeping the infant warm to maintain body temperature at 98° F (37° C)

D. Keeping the infant warm to maintain body temperature at 98° F (37° C) A warm environment is most important, because if the neonate has to maintain body temperature it will further compromise physical status by increasing metabolic activity and oxygen demand. Frequent turning and stimulation are both is contraindicated, because increased activity increases oxygen demands. The oxygen percentage will vary with the neonate's Po 2 values; the concentration of oxygen should never be set at a fixed amount.

A 30-week-pregnant woman reports low backache and abdominal cramps. Which drug may be prescribed if the client is suspected of having preterm labor? A. Methylergonovine B. Mifepristone C. Calcium gluconate D. Magnesium sulfate

D. Magnesium sulfate Low backache and abdominal cramps in a pregnant woman may indicate labor; however, labor pains may not be safe if the gestation is not at full term. Magnesium sulfate may be prescribed to prevent preterm labor. Methylergonovine is prescribed to reduce postpartum uterine hemorrhage. Mifepristone may cause an elective termination of pregnancy. Calcium gluconate may be prescribed to reverse magnesium toxicity.

A pregnant woman is administered medication to treat preterm labor that requires a prescription for calcium gluconate to counter the effects of the drug. Which drug was administered? A. Nifedipine B. Indomethacin C. Betamethasone D. Magnesium sulfate

D. Magnesium sulfate Magnesium sulfate is used to prevent preterm labor in pregnant women with hypertension. To reduce magnesium toxicity caused, calcium gluconate should also be prescribed to counter the effects of this drug. Nifedipine is a calcium channel blocker that inhibits myometrial activity by blocking the calcium influx. Indomethacin is a nonsteroidal antiinflammatory agent used along with sucralfate to protect the stomach. Betamethasone is a corticosteroid used when preterm labor is not maintained by other treatments and delivery is proceeding.

An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned how? A. Breech B. Transverse C. Occiput anterior D. Occiput posterior

D. Occiput posterior Persistent occiput posterior positioning causes intense back pain, the result of fetal compression of the sacral nerves. The breech position is not associated with back pain. The transverse position is not associated with back pain. Occiput anterior, the most common fetal position, generally does not cause back pain.

On admission to the nursery a newborn is found to be experiencing cold stress. What is the nurse's immediate goal at this time? A. Minimize shivering B. Prevent hyperglycemia C. Limit oxygen consumption D. Prevent metabolism of fat stores

D. Prevent metabolism of fat stores If the newborn is cold there is increased brown fat metabolism (nonshivering thermogenesis), which increases levels of fatty acids in the blood, predisposing the infant to acidosis. Newborns do not shiver. Hypoglycemia, not hyperglycemia, may occur because the newborn's glycogen reserves are depleted rapidly when under stress. Although oxygen consumption increases during cold stress, limiting oxygen consumption is not the priority; increased fat metabolism is more serious.

A laboring client has asked the nurse to help her use a nonpharmacologic strategy for pain management. Name the sensory simulation strategy. A. Gentle massage of the abdomen B. Biofeedback-assisted relaxation techniques C. Application of a heat pack to the lower back D. Selecting a focal point and beginning breathing techniques

D. Selecting a focal point and beginning breathing techniques Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. Which component of the complete blood count is of greatest concern to the nurse? A. Platelets B. Hematocrit C. Red blood cells (RBCs) D. White blood cells (WBCs)

D. White blood cells (WBCs) Antineoplastic drugs depress bone marrow, which causes leukopenia; the client must be protected from infection, which can be life threatening. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells. Platelets decrease as rapidly as WBCs, but complications can be limited with infusions of platelets.

(med surg) To prevent capsular formation after breast reconstruction with implants, teach the patient to a. gently massage the area around the implant. b. bind the breasts tightly with elastic bandages. c. exercise the arm on the affected side to promote drainage. d. avoid strenuous exercise until the implant has healed.

a. gently massage the area around the implant.

Nclex question The physician prescribes clomiphene citrate (Clomid) for a woman who has been having difficulty getting pregnant. When teaching the client about this drug's potential side effects, which of the following would the nurse include in the teaching plan? " CHOICES a.) Multiple pregnancies. b.) Increase in spontaneous abortions. c.) Increase in fibrocystic breast disease. d.) Increase in congenital anomalies

a.) Multiple pregnancies.

Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. Applying a moist heating pad to the area at prescribed intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication

b. Applying a moist heating pad to the area at prescribed intervals