CP MB Final Review

125. Which statement made by a nursing student would best indicate that her education on family-centered care was fully understood?

"Childbirth affects the entire family, and relationships will change."

157. A client is scheduled to have a Papanicolaou test. After the nurse teaches the client about the Pap test, which statement by the client indicates successful teaching?

"I will not engage in sexual intercourse for 48 hours before the test."

168. A woman gave birth to a healthy term newborn about 2 hours ago. She asks the nurse about the appearance of her newborn's head. Assessment reveals swelling of the head that extends across the midline. Which response by the nurse would be appropriate?

"The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days."

48. The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. When reporting this suspicion, which finding(s) would the nurse include in the report? Select all that apply.

- dyspnea -tachycardia -PE -bleeding with bruising

47. The nurse is concerned that the child is developing septic shock. Which finding(s) are consistent with this condition? Select all that apply.

- elevated WBC - the child is pale and lethargic -tachypnea -hypotension

78. A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply.

- resp distress -hypoglycemia -jaundice

201. A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

-Assess the axillary temperature every hour. -Review maternal history. -Assess environment for sources of heat loss. -Encourage skin-to-skin contact.

53. A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply.

-Heart rate is 180 beats per minutes. -Oxygen saturation level is 88%. -The infant has facial grimacing and quivering chin.

179. A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply.

-abdominal tenderness -elevated maternal pulse rate -cloudy malodorous fluid

101. A nurse is caring for a client with vaginitis. What teaching(s) should the nurse provide to the client to prevent recurrent vaginal infections?

-avoid using deodorant tampon -avoid douching -wear only cotton panties and ventilated pantyhose

75. A 24-hour-old, full-term, small-for-gestational-age neonate is being assessed. Which maternal factors would the nurse correlate with this gestational age variation?

-blood pressure baseline 140/90 -TORCH - hemoglobin 7g -BKU under 17

184. A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply.

-hypertonicity - excessive sneezing -tremors

109. When the nurse performs the Ortolani maneuver, which action(s) is appropriate? Select all that apply.

-listen for a click -place in supine -attempt to abduct hips 180 degrees

183. A woman visits the prenatal clinic and is noted to have oligohydramnios. The client asks, "Why is this fluid important anyway?" Which statements would be included in the nurse's response? Select all that apply.

-maintains temp - too little can be placental problems -cushion

69. The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation?

-occurs with feeding - no appearance of distress

112. The nursing student is preparing to complete the physical inspection of a female client's external reproductive organs. The mentor determines the student has successfully assessed this client based on documentation of which structures?

-perineum -labia majoria -clitoris

189. A woman who is using an intrauterine system for contraception comes to the clinic. When assessing the woman, which finding(s) would alert the nurse to a possible complication? Select all that apply.

-string length shorter than on initial visit -reports of abdominal pain -ral temperature of 101°F (38.3°C)

84. A nurse is presenting an in-service program about complications that can arise during labor. The nurse determines that the teaching was successful when the group correctly chooses which findings as suggesting an amniotic fluid embolism?

-sudden onset of resp distress -maternal hypotension -maternal tachycardia

171. A preterm newborn is admitted to the neonatal intensive care with the diagnosis of an omphalocele. What nursing actions would the nurse perform? Select all that apply.

-the abdominal contents are protected - fluid loss is minimized - perfused is maintained

163. A 42-year-old woman is 26 weeks' pregnant. She lives at a shelter for female victims of intimate partner violence. Her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of giving birth to a small-for-gestational-age (SGA) infant? Select all that apply.

-the age of the client -living in a shelter for victims of intimate partner violence -vaginal bleeding -blood pressure -positive test for TORCH

The nurse is monitoring a pregnant client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?

2nd

158. A pregnant client in the first trimester reports drinking 3 to 4 cups of coffee with cream and sugar daily and is hoping to cut down. What will the nurse advise to improve pregnancy health outcomes?

Attempt to reduce coffee consumption or replace with decaffeinated coffee to reduce caffeine intake.

On the first prenatal visit, an examination of the client's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. How should the nurse document this finding?

Chadwick sign

155. The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply.

Chlamydia Gonorrhea

60. The nurse caring for an infant with myelomeningocele before surgical intervention will prioritize care in what way?

Cover the sac with a saline dressing

A nurse is planning a continuum of care for a client during pregnancy, labor, and childbirth. What is the most important factor in enhancing the birthing experience?

Educating the client about the improtance of a support person

144. Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution

Her uterus is at the level of the umbilicus.

140. A nurse is conducting a class for a group of young adult women interested in contraception. As part of the class, the nurse asks the group about their understanding about contraception and pregnancy. Which statement(s) would cause the nurse to address it as a misconception. Select all that apply.

If you douche after having sex, you will not get pregnant." "You cannot get pregnant if you have your menstrual period." "Pregnancy cannot happen if my male partner pulls out before ejaculating." "I cannot get pregnant if I am breastfeeding."

66. Amniotic fluid is produced throughout the pregnancy by the fetal membranes. Amniotic fluid has four major functions. What is one of these functions?

Physical protection

A 40-year-old woman is being discharged from the walk-in health care clinic after a diagnosis of pelvic inflammatory disease (PID). Which health teaching topic should the nurse address?

STI

A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?

Uterine Rupture

143. The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect?

Yellowish-brown, seedy stool

114. A nurse is reviewing the maternal history and medical record of an SGA newborn. Which finding would the nurse identify as a placental factor contributing to the newborn's current state?

abnormal cord insertion

169. A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression

128. A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages. The nurse describes which biggest advantage?

allows the baby to pass stools, which helps to reduce bilirubin

54. A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply.

assess the fetal heart rate

151. The nurse informs the client that a diaphragm is an example of which type of contraception?

barrier

A newborn has been diagnosed with a group B streptococcus infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause?

birth canal

126. Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?

cocaine

67. A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?

congenital anomalies

154. The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

convection

86. Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

convection

51. When preparing a class for a group of pregnant women about nicotine use during pregnancy, the nurse describes the major risks associated with nicotine use, including:

decreased birth weight

161. Which cardinal movement of delivery is the nurse correct to document by station?

descent

52. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?

docusate

99. A woman comes to the clinic reporting a greenish-colored discharge from her nipple. On examination, the area below the areola is red and slightly swollen, with tortuous tubular swelling. The nurse interprets these findings as suggestive of which disorder?

duct ectasia

205. A nurse is reviewing the history and physical examination of a client diagnosed with secondary dysmenorrhea for possible associated causes. Which etiology would the nurse need to keep in mind as being the most common?

endometriosis

145. A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:

engorgement

103. A woman comes to the clinic. Assessment reveals a firm, rubbery, movable mass in the upper outer quadrant of the left breast. The edges of the mass are clearly delineated. The nurse interprets these findings as suggestive of which disorder?

fibroadenoma

64. After teaching a woman about breast self-examination, the nurse understands that the teaching was successful when the woman makes which statement?

i'll do the check about a week after my period

95. A nursery nurse is explaining to a new parent about how to assess the newborn for pain. Which manifestation indicates that an infant is in pain?

inability to be consoled

199. During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?

ischial spine

105. A nurse is conducting a class for a group of female adolescents about the structures of the female reproductive tract. The nurse determines that the teaching was successful when the class identifies which structure as containing sweat and sebaceous glands?

labia majora

210. A client has not received any medication during labor. The client is having frequent contractions about every 1 to 2 minutes, has become irritable with the coach, and no longer will allow the nurse to palpate the fundus during contractions. The cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:

late active phase of the first stage of labor.

165. The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?

latent

83. A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she "loses them early." What characteristic(s) place the client in the high-risk pregnancy category? Select all that apply.

low BMI prenatal history homelessness prenatal care

167. A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen

57. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary because:

oxygen demands need to be reduced

147. A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago. Which finding would the nurse expect?

pinkish-brown discharge

170. A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The nurse discusses the risk of transmitting the infection to her newborn, explaining that this infection is transmitted to the newborn through the:

placenta

130. A client at 33 weeks' gestation comes to the emergency department with vaginal bleeding. Assessment reveals the following: Onset of slight vaginal bleeding at 29 weeks with spontaneous cessation Recent onset of bright red vaginal bleeding, more than with previous episode No uterine contractions at present Fetal heart rate within normal range Uterus soft and nontender Based on the assessment findings, which condition would the nurse likely suspect?

previa

207. After teaching a class of newly pregnant women about the many changes the female body undergoes during pregnancy, the nurse determines that the teaching was successful when the class identifies which hormones as being secreted by the placenta? Select all that apply.

relaxin, hCG, estrogen

An infant who is diagnosed with meconium aspiration displays which symptom?

resp distress

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?

showing increased confidence when caring for the newborn

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in

81. A nurse is providing care to a newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding?

temp instability

203. The nurse is caring for a newborn following delivery who has been diagnosed with gastroschisis. Which action(s) by the nurse indicates knowledge of appropriate care for this disorder? Select all that apply.

the nurse assess the color of the newborn's organs radiant warmer hydration status is monitored

182. A client asks the nurse at a prenatal class about acquired disorders. The nurse correctly responds that an acquired disorder:

typically occurs at or soon after birth.

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?

uterine atony

87. The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days?

yellow-green, pasty, unpleasant-smelling stool

209. The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find?

yellowish-green, pasty stool

65. The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?

yellowy mustard color with seedy appearance