Chapter 7 & 8

A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor? 1. Cervix is dilated. 2. Fetal head is engaged. 3. Membranes have ruptured. 4. Uterine contractions are occurring.

1. Cervix is dilated.

How does the nurse identify true labor as opposed to false labor? 1. Cervical dilation is progressive. 2. Contractions stop when the client walks around. 3. Client's contractions progress only in a side-lying position. 4. Contractions occur immediately after the membranes rupture.

1. Cervical dilation is progressive.

A woman in labor hears the health care provider tell the nurse that the fetal lie is longitudinal. The mother ask the nurse what this means to relation to her labor and birth of the baby. How should the nurse respond? 1. "A vaginal birth is possible." 2. "A cesarean birth is possible." 3. "This has no relevance to the labor and impending birth." 4. "Labor probably will be long and you might have back pain."

1. "A vaginal birth is possible."

At a prenatal visit a client who is at 36 weeks' gestation states that she is having uncomfortable irregular contractions. What should the nurse recommend? 1. "Lie down until they stop." 2. "Walk around until they subside." 3. "Time the contractions for 30 minutes." 4. "Take 2 extra-strength aspirins if the discomfort persists."

2. "Walk around until they subside."

A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and 3 cm dilated. The fetal head is at +1 station. In what area of the client's pelvis is the fetal occiput? 1. Not yet engaged 2. Below the ischial spines 3. Entering the pelvicinlet 4. Visible at the vaginal opening

2. Below the ischial spines.

A nurse is caring for a primigravida during labor. What does the nurse observe that indicates birth is about to take place? 1. Bloody discharge from the vagina increases. 2. Perineum begins to bulge with each contraction. 3. Client becomes irritable and stops following instructions, 4. Contractions occur more frequently, are stronger, and last longer.

2. Perineum begins to bulge with each contraction.

A nurse is caring for a client in labor. What client response indicates that the transition phase of labor probably has begun? 1. Assumes the lithotomy position. 2. Perspires and has a flushed face. 3. Indicates back and perineal pain. 4. Exhibits decrease in frequency of contractions.

2. Perspires and has a flushed face.

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client states that she is going to vomit. What phase of the first stage of labor does the nurse suspect the client has entered. 1. Latent 2. Transition 3. Late active 4. Early active

2. Transition

A nurse is teaching a primigravida about how she can identify the onset of labor. What clinical indicator of labor would necessitate the client to call her health care provider? 1. Bloody show and back pressure occur. 2. Contractions become regular or get stronger. 3.Membranes rupture or contractions are 5 to 8 minutes apart. 4. Contractions are 10 to 12 minutes apart and last about 30 seconds.

3. Membranes rupture or contractions are 5 to 8 minutes apart.

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I cannot stand this a minute longer." What does this behavior indicate to the nurse caring for her? 1. There was no preparation for labor. 2. She should receive an analgesic for pain. 3. She is entering the transition phase of labor. 4. Hypertonic uterine contractions are developing.

3. She is entering the transition phase of labor.

A client is admitted to the birthing unit in active labor. What should the nurse expect after an amniotomy is performed? 1. Diminished bloody show. 2. Increased and more variable fetal heart rate. 3. Less discomfort with contractions 4. Progressive dilation and effacement.

4. Progressive dilation and effacement.

The fetus of a client in labor is assessed to be a -1 station. Where did the nurse locate the fetus's head? 1. On the perineum. 2. High in the pelvis. 3. Just below the ischial spines. 4. Slightly above the ischial spines.

4. Slightly above the ischial spines.

A client in active labor is admitted to the birthing room. A vaginal examination reveals the cervix to be 7 cm dilated. On the basis of this finding, what does the nurse expect the client to exhibit? 1. Nausea and vomiting. 2. Bloody and profuse show. 3. Inability to control her shaking legs. 4. Strong contractions with intervals of several minutes.

4. Strong contractions with intervals of several minutes.

A nurse assess the frequency of a client's contractions by timing them from the beginning of a contraction until when? 1. Until the uterus starts to relax. 2. To the end of a second contractions. 3. Until the uterus completely relaxes. 4. To the beginning of the next contraction.

4. To the beginning of the next contraction.

A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy probably is most effective for the client at this time? a. A self-help group b. Psychoanalytic therapy c. A visit with a religious advisor d. Talking with an alcoholic friend

a. A self-help group

A newly admitted client with an obsessive-compulsive personality disorder frequently performs a hand-washing ritual. When attempts are made to set limits on the frequency or length of the ritual, the client's anxiety escalates and the client becomes verbally aggressive. What is the most important for the nurse to do when the client performs the ritual? a. Allow the client sufficient time to carry out the ritual b. Promote reality by showing that the ritual serves little purpose c. Try to ascertain the meaning of the ritual by discussing it with the client d. Interrupt the ritual to demonstrate that the ritual does not control what happens

a. Allow the client sufficient time to carry out the ritual

A nursing assistant interrupts the performance of a ritual by a client with obsessive compulsive disorder. What is the most likely client reaction? a. Anxiety b. Hostility c. Aggression d. Withdrawal

a. Anxiety

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group? a. Change destructive behavior b. Develop functional relationships c. Identify how they present themselves to others d. Understand their patterns of interacting within the group

a. Change destructive behavior

What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol? a. Motivational readiness b. Availability of community resources c. Accepting attitude of the client's family d. Qualitative level of the client's physical state

a. Motivational readiness

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason why this defense is so often used? a. Reduces their feelings of guilt b. Creates the appearance of independence c. Helps them live up to others' expectations d. Makes them look better in the eyes of others

a. Reduces their feelings of guilt

A client who has participated in caring for her infant in the neonatal intensive care unit (NICU) for several days in preparation for the infant's discharge comes to the unit on the the last hospital day with an alcohol odor on her breath ad slurred speech. What action should the nurse take? a. Talk with the mother about her condition and assess her willingness to participate in an alternate discharge plan b. Request that the mother wait in the hospital lobby and call the health care provider to cancel the discharge order c. Speak to the mother about her condition and have her see a social worker about the infant's discharge to a foster home d. Continue with the discharge procedure and alert the home health nurse that the mother needs an immediate follow-up visit

a. Talk with the mother about her condition and assess her willingness to participate in an alternate discharge plan

A client with mild preeclampsia is told that she must restrict her activities and rest in bed several times a day. The client starts to cry and tells the nurse that she has two small children at home who need her. How should the nurse respond? a. "You'll need someone to help you care for the children." b. "You are worried about how you will be able to manage." c. "You can get a neighbor to help out, and your husband can do the housework." d. "You'll be able to fix light meals, and the children can go to day care for a few hours each day."

b. "You are worried about how you will be able to manage."

A nurse is caring for a client with a generalized anxiety disorder. Which factor should be assessed to determine the client's present status? a. Memory b. Behavior c. Judgment d. Responsiveness

b. Behavior

A client in a psychiatric hospital with the diagnosis of major depression is tearful and refuses to eat dinner after a visit with a friend. What is the most therapeutic nursing action? a. Allow the client to skip the meal b. Offer an opportunity to discuss the visit c. Reinforce the importance of adequate quiet thinking time d. Provide the client with adequate quiet thinking time

b. Offer an opportunity to discuss the visit

A 20-year-old college student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most appropriate response by the nurse? a. "With whom have you shared your feelings of anxiety?" b. "What have you identified as the cause of your anxiety?" c. "It has been difficult for you. How long has this been going on?" d. "Let's talk about your problems. Are you having difficulty adjusting?"

c. "It has been difficult for you. How long has this been going on?"

A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect is the cause of the bleeding? a. Placenta previa b. Tubal pregnancy c. Abruptio placentae d. Spontaneous abortion

c. Abruptio placentae

A client's severe anxiety and panic are often considered to be "contagious." What action should be taken when a nurse's personal feelings of anxiety are increasing? a. Refocus the conversation on some pleasant topics b. Say to the client, "Calm down. You are making me anxious, too." c. Say, "Another staff member is coming in. I will leave and return later." d. Remain quiet so that personal feelings of anxiety do not become apparent to the client

c. Say, "Another staff member is coming in. I will leave and return later."

After giving birth to her third child, a client tearfully says to the nurse, "How much more can I give myself?' What should the nurse consider when applying mental health principles to the care of any person with children?" a. It is easier to adjust to the first child than to later ones b. It is pathologic to feel anger and resentment toward a child c. Some parents experience feelings of resentment toward their children d. Parents usually have inborn feelings of love and acceptance of their children

c. Some parents experience feelings of resentment toward their children

A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention? a. Introducing the client to one other client b. Requiring participation in therapy sessions c. Encouraging interaction with others in small groups d. Conveying an attitude of concern that is not intrusive

d. Conveying an attitude of concern that is not intrusive

A nurse is planning for the discharge of a crack-addicted 17-year-old mother and her newborn. What is the most appropriate referral to meet the mother's and the infant's needs? a. Legal aid b. Family court c. Foster parent care d. Home health nurse

d. Home health nurse

A nurse is assessing a client with depression without psychotic features. Which manifestation reflects a disturbance in affect related to depression? a. Echolalia b. Delusions c. Confusion d. Hopelessness

d. Hopelessness

A client is diagnosed with generalized anxiety disorder. For what behavior should the nurse asses a client to determine the effectiveness of therapy? a. Participates in activities b. Learns how to avoid anxiety c. Takes medication as prescribed d. Identifies when anxiety is developing

d. Identifies when anxiety is developing

A client who uses ritualistic behavior taps other clients on the shoulders three times while going through the ritual. The nurse infers that this client has a what? a. Blurred personal identity b. Poor control of sudden urges c. Disturbance in spatial boundaries d. Reduced ability to adapt to life's stresses

d. Reduced ability to adapt to life's stresses