312 Exam 1 Practice Questions

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects to the fetus.

The nurse is working in the labor and birth unit when a client with active herpes simplex virus-Type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care is anticipated?

Prepare the client for a cesarean section. The nurse is most accurate to prepare for a cesarean section because the client has an active lesion and does not want to transmit the virus to the newborn. Antibiotic therapy, at this time, does not prevent the transmission of the infection. A full assessment is always completed on the newborn and is not an adjustment in the plan of care. Antibacterial ointment is not placed on the mother's lesions.

A nurse is caring for a 16-year-old pregnant adolescent. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?

a glass of orange juice Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

beginning of one contraction to the beginning of the next contraction

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?

blue an alkaline reaction.

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?

fundus two fingerbreadths above the umbilicus Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum.

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should

obtain more data before giving the caller any confidential information.

A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

using a peri bottle to clean the perineum after each voiding or bowel movement

Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider?

A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps

The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month-pregnant client performs what action?

Leopold's maneuvers The nurse assesses for these through Leopold's maneuvers, a series of four palpations of the uterus and fetus through the abdominal wall.

A multiparous client 48 hours postpartum who is breastfeeding tells the nurse, "I'm having a lot of cramping. This didn't happen when I nursed my first baby." Which would be the nurse's best response?

"The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin."

Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which action?

Allow the 5-year-old undivided attention several times a day.

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?

Assess the fetal heart rate. Assessing the fetal heart rate is always a priority after spontaneous rupture of membranes has occurred. Meconium-stained fluid is also a common sign of fetal distress related to an inadequate transfer of oxygen to the fetus. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary.

Thirty minutes ago, a term multigravida was 5 cm dilated, 100% effaced, and −1 station. She is now visibly uncomfortable and states that she needs to get up for a bowel movement. What is the best nursing intervention?

Perform another sterile vaginal examination on the client.

A client is in the first stage of labor. She asks the nurse what the best physical position is to promote labor progression and efficient uterine contractions. What response by the nurse is most appropriate?

The best option at this stage is to ambulate."

A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks only Mandarin, and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which response indicates that the client may be approaching birth?

The fetal monitor strip shows early decelerations.

A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. What should the nurse tell the client that the test results indicate?

There is evidence of fetal well-being.

The fetus of a multigravid client at 38 weeks' gestation is determined to be in a frank breech presentation. The nurse describes this presentation to the client as which fetal part coming in contact with the cervix?

butt

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals. To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals.

A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate

drug dependence

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to

enhance bonding by pointing out the neonate's features. Pointing out neonate's features to the mother enables the mother to begin to bond with him. The nurse should encourage this important activity from the time of the neonate's admission to the NICU. Explaining the NICU visiting policy, obtaining a family medical history, and questioning the mother about her preterm labor don't take priority over enhancing maternal bonding.

A client is having a level 2 ultrasound. A nurse knows that physicians order this procedure

for diagnostic purposes when fetal development is in question. Level 2 ultrasound is more sophisticated and can visualize fetal structures more clearly than a level 1 ultrasound. It's used for diagnostic purposes when fetal development is in question. Typically, level 1 ultrasound is used to assess gestational age. Diagnostic ultrasounds aren't ordered to satisfy the client's curiosity or to provide images of the fetus for family and friends.

A nurse is caring for a client in the 13th week of pregnancy who develops hyperemesis gravidarum. The nurse is reviewing the client's laboratory report. Which finding indicates the need for intervention?

ketones in urine Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L (4 mmol/L), and a serum sodium level of 140 mEq/L (140 mmol/L) are all within normal limits.

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate. During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?

Contractions will be stronger and more uncomfortable and will peak more abruptly

The primary health care provider prescribes whole blood replacement for a multigravid client with abruptio placentae. What should the nurse do first before administering the intravenous blood product?

Validate client information and the blood product with another nurse.

A 15-year-old client who is 26 weeks pregnant has been admitted to the labor and delivery unit with reports of abdominal pain. Her parents want to speak with a nurse about her condition. How should the nurse respond?

"I'll need a signed consent from your daughter to give you medical information." A pregnant minor is emancipated from her parents so she can make decisions for herself and her baby. Therefore, the client's right to confidentiality means that neither the nurse nor the health care provider may divulge medical information without a signed consent.

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of the fetus. The client's BPP score is 8. What does this score indicate?

The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may be repeated if the score isn't within normal limits.

A client who is 6 months postpartum asks the nurse about an effective method of birth control. What is the nurse's most appropriate response?

"Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding."\ birth control pills that contain estrogen should not be taken

The nurse caring for a postpartum client recalls which of the following are appropriate instructions for the prevention of a urinary tract infection (UTI)? Select all that apply.

"Drink at least eight 8-ounce glasses of water daily" "Set your phone alarm to remind you to change your peri-pad every one to two hours" "Remember to empty her bladder completely every 2-4 hours"

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor?

effects of analgesic medication

After teaching the parent of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly, the nurse determines that the teaching was successful when the parent describes the condition in which way?

"There is a blind upper pouch and an opening from the esophagus into the airway." Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fistula from the esophagus into the trachea

A 36-year-old multipara client is 20 weeks gestation and comes to the prenatal clinic in distress. She has been experiencing edema of her lower extremities and headaches two to three times a week. She is worried about her pregnancy and her own health. What is an appropriate response from the nurse?

"I am glad you came in. We need to do more assessments." The client's symptoms need to be explored further to rule out hypertension and other possible complications of pregnancy. Her symptoms are not urgent enough at this point to refer her to her physician but may be after the nurse has assessed her further. The responses telling her not to worry and that she should expect symptoms dismiss the concerns of the client. These concerns should be explored.

While the nurse is performing a complete assessment of a term neonate, which finding would alert the nurse to notify the health care provider (HCP)?

expiratory grunt An expiratory grunt is significant and should be reported promptly because it may indicate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts. The presence of a red reflex in the eyes is normal. An absent red reflex may indicate congenital cataracts. A respiratory rate of 45 breaths/min and a prominent xiphoid process are normal findings in a term neonate.

A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching?

herbal remedies A pregnant woman should avoid all medication unless instructed by the physician. This includes herbal remedies, because their effects on the fetus have not been identified. Meditation, music therapy, and acupuncture have all proven to enhance relaxation without harm to the mother or baby.

A diabetic postpartum client plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement?

"Breastfeeding will assist in lowering maternal blood glucose." Breastfeeding consumes maternal calories and requires energy which increases the maternal basal metabolic rate and assists in lowering the maternal blood glucose level. Insulin is not transferred to the infant through breast milk. Breastfeeding is recommended for diabetic mothers because it does lower blood glucose levels. The number of antibodies in breast milk is not altered by maternal diabetes.