HESI EAQ sexuality/reproduction
Which response would the nurse provide to the client who is asking for guidance about sexual activity in pregnancy?
1 "You should discontinue intercourse after the second trimester." 2 "This information can be given only by your obstetrician or nurse-midwife." Correct 3 "With an uncomplicated pregnancy, there are no limitations on sexual activity." 4 "Sexual activity should be avoided during the first and last 6 weeks of pregnancy."
Which response by the nurse is best when a client who has had an ST segment elevation myocardial infarction (STEMI) asks about the resumption of sexual activity?
1 "You can safely resume sexual activities when you are no longer fearful of sexual intimacy." 2 "You will be able to discuss sexual activity with the health care provider before discharge." Correct 3 "Sexual activities can be safely resumed after an exercise stress test with no heart symptoms." 4 "Many clients wait a few weeks after myocardial infarction before having any sexual activity."
A client who has had a cesarean birth is being discharged. Which statement indicates to the nurse that further teaching is required?
1 "I may take an oxycodone/acetaminophen (Percocet) tablet if my incision hurts." 2 "I should take a mild laxative if I don't have a bowel movement." 3 "I can start mild exercises once my incision has stopped hurting." Correct 4 "I don't need perineal care because I didn't give birth through the vagina."
Which statement made by a client supports the previous diagnosis of late-stage (tertiary) syphilis?
1 "I noticed a wart on my penis." 2 "I have sores all over my mouth." 3 "I've been having a sore throat lately." Correct 4 "I'm having trouble with my balance."
The nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STIs). Which statement by the client indicates effective learning?
1 "I will use condoms when having sex with an infected partner." 2 "I will perform a genital self-examination every month before bathing." 3 "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." Correct 4 "I will consult with my primary health care provider when there is a rash or ulcer on my genitalia."
A client diagnosed with sexual dysfunction states, "Well, I guess my sex life is over." Which response would the nurse use as a reply?
1 "I'm sorry to hear that." 2 "Oh, you have a lot of good years left." Correct 3 "You are concerned about your sex life?" 4 "Have you asked your primary health care provider about that?"
After receiving a diagnosis of placenta previa, the client asks the nurse what this means. Which is an appropriate response?
1 "It's premature separation of a normally implanted placenta." 2 "Your placenta isn't implanted securely in place on the uterine wall." 3 "You have premature aging of a placenta that is implanted in your uterine fundus." Correct 4 "The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."
A postpartum client receiving an intravenous infusion of oxytocin to stimulate labor asks the nurse why it is not being discontinued now that the baby is born. Which response by the nurse is most appropriate?
1 "The oxytocin promotes the flow of lochia." Correct 2 "The contractions prevent excessive bleeding." 3 "The oxytocin eases the discomfort of involution." 4 "The oxytocin enhances the healing of tissue in the uterus." Oxytocin intensifies contractions of the uterus and promotes return of the uterus to its prepregnant state. It is sometimes used after delivery to prevent hemorrhage caused by uterine atony. As the uterus contracts, the flow of lochia decreases. Oxytocin tends to worsen, not ease, discomfort; the client may experience pain as the uterus contracts. Oxytocin does not promote tissue healing.
Which client requires nonurgent treatment after a mass casualty incident?
1 A neonate with body temperature of 103°F 2 An older adult person with a rapidly falling pulse Correct 3 A middle-aged man with skin rash from shaving 4 A pregnant woman with blood pressure (BP) of 140/90 mm Hg
Which is the desired outcome for the intrapartum client during the third stage of labor?
1 Absence of discomfort Correct 2 Firmly contracted uterine fundus 3 Efficient fetal heart beat-to-beat variability 4 Maternal respiratory rate within the expected range
Which factor identified in a client's history places her at increased risk for breast cancer?
1 Active lifestyle 2 Low-income background 3 Delayed onset of menarche Correct 4 Late beginning of childbearing
A 28-year-old woman is scheduled to undergo a laparoscopic bilateral salpingo-oophorectomy. Which concern would the nurse expect to be the most prominent for the client?
1 Acute pain 2 Risk for hemorrhage 3 Fear of chronic illness Correct 4 Loss of childbearing potential
When would the risk of another seizure in a client with eclampsia decrease?
1 After birth occurs 2 After labor begins Correct 3 48 hours postpartum 4 24 hours postpartum
Which is the most appropriate nursing intervention for a client admitted to the high-risk prenatal unit at 35 weeks' gestation with a diagnosis of complete placenta previa?
1 Applying a pad to the perineal area Correct 2 Having oxygen available at the bedside 3 Allowing bathroom privileges with assistance 4 Educating the client regarding the intensive care nursery
A 36-year-old primigravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, which nursing intervention is of the highest importance at this time?
1 Assessing the fetal heart rate for tachycardia 2 Promoting adequate urine output by offering oral fluids 3 Monitoring respiratory status and ascertaining that calcium gluconate is at the bedside Correct 4 Notifying the primary health care provider regarding the epigastric pain, headache, and blurred vision
Which clinical data indicate that the client at 39 weeks' gestation is in true labor?
1 Contractions occur every 10 minutes with no change in frequency over 2 hours, and the cervix is closed. 2 Contractions are not evident; the cervix is dilated 3 cm and 50% effaced, and there is no change after 4 hours of staying out of bed. Correct 3 Contractions occur every 5 to 10 minutes, the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours. 4 Contractions are irregular, occurring every 10 to 15 minutes, the cervix is dilated one fingertip and is 50% effaced, and there is no change with 4 hours of bed rest.
A client in labor is admitted to the birthing unit 20 hours after her membranes have ruptured. Which complication would the nurse anticipate when assessing the character of the client's amniotic fluid?
1 Cord prolapse 2 Placenta previa Correct 3 Maternal sepsis 4 Abruptio placentae Prolonged rupture of membranes of more than 18 hours increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection. Cord prolapse usually occurs shortly after the membranes rupture; it is unlikely that it will occur 20 hours after the membranes have ruptured. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Abruptio placentae is premature separation of a normally implanted placenta; it, too, is unrelated to ruptured membranes.
A client receiving treatment for premenstrual syndrome visits the primary health care provider with complaints of headache and dry mouth. Which medications would be responsible for these side effects? Select all that apply. One, some, or all responses may be correct.
1 Danazol 2 Ibuprofen Correct 3 Sertraline Correct 4 Fluoxetine Correct 5 Escitalopram Medications used to treat premenstrual syndrome include sertraline, fluoxetine, and escitalopram. The side effects of these medications are headaches, dry mouth, dizziness, and sleep disturbances. Danazol is used to treat endometriosis. Side effects are edema and oily skin. Ibuprofen is used to treat primary dysmenorrhea. The side effects include nausea, vomiting, and indigestion.
Which pregnancy hormone is thought to cause the nausea and vomiting the client is experiencing in the first trimester of pregnancy?
1 Estrogen 2 Progesterone 3 Human placental lactogen (hPL) Correct 4 Human chorionic gonadotropin (hCG)
Which information is important for the nurse to obtain during the assessment of a female taking oral contraceptives? Select all that apply. One, some, or all responses may be correct.
1 Family socioeconomic status 2 Maternal history for estimated gestation Correct 3 History of thromboembolic disorder Correct 4 Medication interactions leading to a decreased effect of oral contraceptives Correct 5 Medications prescribed that may have therapeutic effects decreased if taken with oral contraceptives
Which is a potential cause of fetal tachycardia when a client is in active labor?
1 Fetal head compression 2 Umbilical cord compression Correct 3 Increased maternal metabolism 4 Pudendal anesthesia administration
Which is correct regarding the safety of caffeinated beverages during pregnancy? Select all that apply. One, some, or all responses may be correct.
1 High intake causes congenital disabilities. Correct 2 One 12-ounce cup of coffee per day is probably fine. Correct 3 High consumption is often related to a decrease in birth weight. 4 Pregnant women should try to abstain from caffeine completely. 5 Caffeine does not increase the risk for miscarriage, regardless of the amount consumed. 6 There is no effect of caffeine on the fetus in the third trimester. One 12-ounce cup of coffee per day is probably fine. A high intake of caffeine is often related to a decrease in birth weight. It does not cause congenital disabilities. All pregnant women do not need to abstain from caffeine completely; this is an individual choice. High intakes of caffeine during pregnancy might increase the risk of miscarriage. It is not true that a woman need not worry about caffeine intake once she has entered the third trimester; the recommendation remains no more than one 12-ounce cup daily.
A client is receiving magnesium sulfate therapy for severe preeclampsia. Which initial sign of toxicity would prompt the nurse to intervene?
1 Hyperactive sensorium 2 Increase in respiratory rate Correct 3 Lack of the knee-jerk reflex 4 Development of a cardiac dysrhythmia
Which assessment finding would the nurse expect in a client with untreated preeclampsia?
1 Increased blood pressure of 150/100 mm Hg 2 Increased blood pressure that is accompanied by a headache 3 Blood pressure above the baseline that fluctuates with each reading Correct 4 Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria
Where would the nurse expect the fundus to be located 3 days after a cesarean birth?
1 One fingerbreadth below the umbilicus 2 Two fingerbreadths below the umbilicus Correct 3 Three fingerbreadths below the umbilicus 4 Four fingerbreadths below the umbilicus
A client wants to abort her pregnancy after 4 months of gestation. For which oral medication would the nurse anticipate providing teaching?
1 Oxytocin Correct 2 Misoprostol 3 Indomethacin 4 Dinoprostone Misoprostol is an oral medication used to induce an abortion. Oxytocin is available as an injection; it is used to induce labor at or near full-term gestation. Indomethacin is used to maintain a pregnancy during preterm labor. Dinoprostone is used to induce an abortion; it is available only for vaginal use.
A woman in the third trimester of pregnancy presents with vaginal bleeding and states she snorted cocaine approximately 2 hours ago. Which complication would this client profile suggest?
1 Placenta previa 2 Tubal pregnancy Correct 3 Abruptio placentae 4 Spontaneous abortion
A client who has missed two menstrual periods arrives at the prenatal clinic with vaginal bleeding and one-sided lower quadrant pain. Which condition would the nurse suspect?
1 Placenta previa Correct 2 Ectopic pregnancy 3 Incomplete abortion 4 Rupture of a graafian follicle
Which would the nurse include when teaching clients about the potentially serious consequences of using diuretics during pregnancy? Select all that apply. One, some, or all responses may be correct.
1 Preeclampsia Correct 2 Severe hypovolemia 3 Acute hypervolemia 4 Gestational diabetes Correct 5 Reduced placental perfusion Severe hypovolemia and reduced placental perfusion are two potentially serious consequences of using diuretics during pregnancy. Preeclampsia, acute hypervolemia, and gestational diabetes are not among the potentially serious consequences of using diuretics during pregnancy.
Which condition in the gynecological history of the client scheduled for hysterectomy causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy?
1 Prolapsed uterus Correct 2 Large uterine fibroids 3 Mild dysplasia of the cervical os 4 Urinary incontinence when coughing
Which goal would the client with dysmenorrhea seeking treatment want to achieve?
1 Reducing the pad saturation rate 2 Making intercourse less uncomfortable Correct 3 Easing the pain of the client's menstruation 4 Eliminating bleeding between menstrual periods
A client's cervix is fully dilated and effaced. The head of the fetus is at +2 station. Which client action would the nurse encourage during contractions?
1 Relax by closing her eyes Correct 2 Push with her glottis open 3 Blow to slow the birth process 4 Pant to prevent cervical edema
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. Which finding would the nurse expect when inspecting the perineum?
1 Small tears 2 Greenish-yellow amniotic fluid Correct 3 Enlarging area of caput with each contraction 4 An increasing amount of amniotic fluid with each contraction
A client with a human immunodeficiency virus (HIV) infection reports genital discharge associated with irritation, pain, and itching. Which actions of the client might have led to this condition? Select all that apply. One, some, or all responses may be correct.
1 Taking diethylstilbestrol 2 Taking iron supplements Correct 3 Wearing tight jean pants 4 Performing Kegel exercises Correct 5 Using antibiotic medications Discharge from the genital area is commonly observed in clients with sexually transmitted diseases such as HIV. Genital discharge causes irritation, pain, and itching and may be triggered when the client wears tight jean pants, and when the client is using antibiotics. Diethylstilbestrol, iron supplements, and Kegel exercises do not cause genital discharge.
Which would the nurse assess for in a male child prescribed an androgen?
1 Tendon rupture 2 Delayed puberty 3 Cartilage erosion Correct 4 Decreased height
Which medication is safe for the nurse to administer to a lactating woman but may cause teratogenic effects when administered to pregnant clients?
1 Tetracycline 2 Methotrexate Correct 3 Carbamazepine 4 Cyclophosphamide Carbamazepine is safe to administer in a lactating woman but may cause neural tube defects as a teratogenic effect. Tetracycline may cause tooth and bone abnormalities as a teratogenic effect. Methotrexate may cause limb malformations as a teratogenic effect. Cyclophosphamide may cause secondary cancer as a teratogenic effect. Tetracycline, methotrexate, and cyclophosphamide should not be administered to breast-feeding women.
The nurse would demonstrate to the partner of the client experiencing back pain in labor that counterpressure would be applied to which area in the image below?
1 a 2 b 3 c Correct 4 d Counterpressure on the lower sacrum (point d) helps alleviate the painful internal sensations that occur when the fetal head places pressure on the spinal nerves. Lower back pain can be most pronounced when the fetal head is in the occiput posterior position. Counterpressure at points a, b, and c would not address the site where lower back pain occurs in labor.
The postpartum nurse is providing care to four maternal/infant couplets who have all delivered within the past 24 hours. After receiving the handoff report from the off-going nurse, which client is a priority for the nurse to see first?
1 The term infant with a heart rate of 158 beats/min 1 hour after birth 2 The mother who has saturated one peripad over the 4 hours since delivery Correct 3 The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 4 The mother with a white blood cell count of 12,500/mm3; (12.5 × 109/L) 24 hours after delivery
Which preventive wellness recommendations will the nurse make to a male client who tests positive for the BRCA mutation after his mother and two sisters are found to carry the gene? Select all that apply. One, some, or all responses may be correct.
Correct 1 Get a baseline mammogram at 40 years. 2 Get prostate screenings starting at the age of 50. Correct 3 Get breast self-examination (BSE) training at 35 years. Correct 4 Get a clinical breast examination (CBE) every 6 months starting at 35 years. 5 Get a clinical breast examination every 6 months beginning at 40 years.
The nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which assessment finding would prompt the nurse to withhold the medication and notify the primary health care provider?
1 Urine output of 30 mL/h 2 Respirations of 14 breaths/min Correct 3 Absence of deep tendon reflexes 4 Blood pressure of 140/100 mm Hg A side effect of magnesium sulfate is depressed reflex responses; this may indicate toxicity, and intervention is necessary. The amount of urine output is important, because oliguria may signify magnesium toxicity, but 30 mL/h is within the acceptable range. A respiratory rate of 14 breaths/min is a positive sign that toxicity has not occurred. A respiratory rate of 12 breaths/min or slower is a concern that requires nursing intervention. The blood pressure is expected to increase; this medication is administered to prevent a seizure, not to lower blood pressure.
A pregnant client who has a history of cardiac disease asks how to relieve occasional heartburn. The nurse would instruct the client to avoid antacids containing which ingredient?
Correct 1 Sodium 2 Calcium 3 Aluminum 4 Magnesium
Which statement indicates a client understands transmission of the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct.
Correct 1 "I can contract HIV by participating in oral sex." 2 "I can contract HIV by eating from used utensils." Correct 3 "HIV is contracted by using contaminated needles." 4 "I can contract HIV by using the bathroom of a person who is HIV positive." Correct 5 "Babies can contract HIV because of contact with maternal blood during birth."
A physically active 19-year-old primigravida attends the prenatal clinic for the first time. She asks the nurse whether she may continue playing tennis and riding horses while she is pregnant. How would the nurse reply?
Correct 1 "Tell me more about how you engage in these activities." 2 "Horseback riding is acceptable, but only up to the last trimester." 3 "Tennis is good exercise for you, but horseback riding is too strenuous." 4 "Both of these sports have been found to be too strenuous for a pregnant woman."
The nurse is teaching clients how to determine the estimated time of ovulation by taking their basal body temperature. Which is the expected change in the basal temperature during ovulation?
Correct 1 A slight drop followed by an increase 2 A sudden rise followed by a decrease 3 A marked increase, after which the temperature gradually increases more 4 A marked decrease, after which the temperature remains lower
A woman in active labor arrives at the birthing unit. She tells the nurse that she was told that she had a chlamydial infection the last time she visited the clinic; however, she stopped taking the antibiotic after 3 days because she "felt better." In light of this history, which would the nurse anticipate as part of the plan of care?
Correct 1 Administration of antibiotics before delivery 2 Oxytocin infusion to augment labor 3 Epidural anesthesia to relieve difficult labor discomfort 4 Magnesium sulfate infusion to prevent a precipitous birth
Which test would be used to determine fetal lung maturity in a client in preterm labor?
Correct 1 Amniocentesis 2 Ultrasonography 3 Measurement of human gonadotropin hormone 4 Chorionic villus sampling The presence of phosphatidylglycerol and a 2:1 lecithin to sphingomyelin ratio in the amniotic fluid confirm fetal lung maturity. Ultrasonography cannot be used to determine fetal lung maturity. The measurement of human chorionic gonadotropin hormone is most commonly used to diagnose pregnancy. Chorionic villus sampling, a diagnostic screening test, is done between the 8th and 12th weeks of pregnancy to determine fetal chromosomal status.
Which behavioral findings correspond to intimate partner violence in young adolescents? Select all that apply. One, some, or all responses may be correct.
Correct 1 Attempting suicide 2 Sexually acting out Correct 3 Pattern of substance abuse 4 Fear of certain people or places 5 Preoccupation with others' or one's own genitals
A client's cervix is dilated to 7 cm, and the presenting part is low in the midpelvis. Which instruction would the nurse give the client to help alleviate discomfort during contractions?
Correct 1 Deep-breathe slowly. 2 Perform pelvic rocking. 3 Use the panting technique. 4 Begin patterned, paced breathing.
Which client would the nurse expect to experience the most severe afterbirth pains?
Correct 1 Grand multipara 2 Breast-feeding primipara 3 Primipara with a vaginal delivery 4 Woman with a cesarean delivery at 43 weeks' gestation
An adolescent client is diagnosed with dysfunctional uterine bleeding. Which assessment finding in the adolescent's history may be relevant? Select all that apply. One, some, or all responses may be correct.
Correct 1 History of trauma to the vagina Correct 2 Presence of malignant lesions 3 Family history of vaginal bleeding Correct 4 Medical history indicating iatrogenic causes 5 History of early menarche
Which would the nurse include when educating an adolescent about herpes simplex virus 2 (HSV-2)? Select all that apply. One, some, or all responses may be correct.
Correct 1 Illness or stress can result in outbreaks. Correct 2 Use lubricant during sexual encounters. Correct 3 Treatment is intended to prevent outbreaks. 4 A one-time dose of oral azithromycin is curative. Correct 5 Condoms should be used to decrease transmission.
A client with mumps reports pain, inflammation, and swelling of the testes. Which condition would the nurse suspect?
Correct 1 Orchitis 2 Salpingitis 3 Ductal ectasia 4 Fibroadenoma
A female client with Hodgkin disease is to begin chemotherapy and is concerned that sterility may result because of treatment. On which information would the nurse base the response?
Correct 1 Ova can be harvested and frozen for future use. 2 Chemotherapy is not radical enough to destroy ovarian function. 3 Ovarian function will be temporarily destroyed but will return in time. 4 Radiation can be substituted for chemotherapy to preserve ovarian function.
A pregnant woman with cervical stenosis has been admitted to the hospital for a labor induction. Which medication would the nurse anticipate administering?
Correct 1 Oxytocin 2 Misoprostol 3 Dinoprostone 4 Ergot alkaloids
Initial vaginal examination reveals that a client's cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. Which is the correct documentation of this delivery?
Correct 1 Precipitous vaginal delivery 2 Prolonged transitional phase 3 Primigravida primary delivery 4 Normal spontaneous vaginal delivery
A woman arrives for an appointment at an obstetrics clinic. During the visit the nurse records the following information. Which finding indicates a need for future intervention?
Correct 1 Rubella titer less than 1:8 (nonimmune) 2 No fetal heartbeat heard with fetoscope 3 Hemoglobin 11 g/dL, hematocrit 31% 4 Maternal blood type A-negative, father O-negative
A lactating woman is diagnosed with depression. Which is the medication of choice for this client if she wishes to continue breast-feeding?
Correct 1 Sertraline 2 Fluoxetine 3 Sumatriptan 4 Bromocriptine
During which week of gestation would a ruptured tubal pregnancy most commonly occur?
Correct 1 Sixth 2 Twelfth 3 Sixteenth 4 Eighteenth
How would the nurse explain a contraction stress test (CST) result interpreted as negative in a client at 41 weeks' gestation?
Correct 1 The fetus at this time is likely to tolerate the stress of labor. 2 The test should be repeated in 24 hours because the examination results indicate hyperstimulation. 3 Immediate birth should be considered because there is no fetal heart acceleration with fetal movement. 4 A trial induction should be started because fetal heart rate acceleration with movement indicates a false result.
A laboring client receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. Which would be the nurse's immediate action?
Correct 1 Turning the client on her side 2 Checking the vaginal area for bleeding 3 Notifying the primary health care provider 4 Checking the fetal heart rate every 3 minutes
Which surgeries are associated with permanent contraception? Select all that apply. One, some, or all responses may be correct.
Correct 1 Vasectomy 2 Cryosurgery 3 Mastectomy 4 Varicocelectomy Correct 5 Tubal ligation Vasectomy is the surgical removal of a portion of the vas deferens, which is considered to be a form of male permanent contraception or sterilization. In tubal sterilization, the fallopian tubes are ligated. Tubal sterilization is a form of permanent contraception. Cryosurgery is used to treat and kill abnormal cells with the aid of subfreezing temperature. The surgical removal of either one or both the breasts is called mastectomy and is included in the treatment of breast cancer. The surgery performed to repair the varicose veins of the scrotum is called varicocelectomy.
After a client's membranes rupture spontaneously, the umbilical cord is protruding from the vagina. What is the order of priority for the following nursing interventions?
Correct1. Call for assistance and don sterile gloves. Correct2. Insert two fingers into the vagina, and exert upward pressure against the fetal presenting part. Correct3. Put a rolled towel under one hip and place the client in the modified Sims position. Correct4. Administer oxygen to the mother, and monitor fetal heart tones.
Arrange the series of steps involved for the nurse assisting a primary health care provider with a hysterosalpingography procedure for a client.
Hysterosalpingogram is used to visualize the cervix, uterus, and fallopian tubes in the clients with uterine problems such as fibroids, tumors, and fistulas. A client with intrauterine fibroids must appear for the examination during the first 14 days of the menstrual cycle, which reduces the chance that the client may be pregnant. Confirm the date of the client's last menstrual period. It is always advisable to ask the client about allergies to iodine dye used in the procedure. Then, place the client in lithotomy position to allow the insertion of a speculum to view the cervix. Iodine dye is then injected through the cervix to fill and highlight the interior of the cervix, uterus, and fallopian tubes. Correct 4.Placing the client in the lithotomy position
A healthy couple whose child has cystic fibrosis (CF) is concerned about having another child with the disease. Knowing that this disorder has an autosomal-recessive mode of inheritance, how would the nurse respond?
1 "There is a 50% chance that this baby will also be affected." 2 "If this baby is male, there is a 50% chance of his being affected." 3 "If this baby is female, there is no chance of her being affected, but she will be a carrier." Correct 4 "There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier."
Which response would the nurse give to a primigravida at 9 weeks' gestation who asks when she can first expect to feel her baby move?
1 "You should be able to feel the baby move any day now." 2 "You should feel your first light movement of the baby around 24 weeks." 3 "Most women can first detect movement of their babies by 12 to 14 weeks." Correct 4 "Many women are able to first feel light movement between 18 and 20 weeks."
A client who menstruates regularly every 30 days asks the nurse on what day she is most likely to ovulate. The client's menses started January 1. Which day in January would the nurse tell her that ovulation should occur?
1 7 Correct 2 16 3 24 4 29
When caring for a woman with a probable ruptured tubal pregnancy, which clinical manifestation requires immediate intervention?
1 Abdominal distention 2 Intermittent abdominal contractions 3 Dull, continuous upper-quadrant abdominal pain Correct 4 Sudden onset of knifelike pain in one of the lower quadrants
A client diagnosed with stage 2 syphilis would probably experience which symptoms? Select all that apply. One, some, or all responses may be correct.
1 Ataxia Correct 2 Alopecia Correct 3 Weight loss 4 Gummas on the skin Correct 5 Mucous patches in the mouth
The nurse teaches a nursing student about teratogens and the effect on fetuses. After reviewing client documentation by the student on exposure to teratogens and the effect, which information would the nurse identify as needing correction?
1 Client 1 2 Client 2 3 Client 3 Correct 4 Client 4 The absence of eyeballs is a teratogenic effect on the fetus caused by maternal exposure to nitrofurantoin, not valproic acid. Danazol exposure causes masculinization of a female fetus. Valproic acid may cause neural tube defects. Nitrofurantoin may cause cleft lips with cleft palates.
Based on the medication chart, the nurse would need to notify the health care provider regarding which client?
1 Client A Correct 2 Client B 3 Client C 4 Client D Genital herpes is an acute, recurring, incurable viral infection caused by herpes simplex virus. Antiviral drugs such as acyclovir and famciclovir are used to treat genital herpes, not benzathine penicillin G, which is an antibiotic. Client B's prescription indicates a need for correction, so the nurse would notify the health care provider. Chlamydia is a sexually transmitted infection caused by Chlamydia trachomatis. Azithromycin is used to treat chlamydia. Genital warts are treated with imiquimod. Gonorrhea is treated with doxycycline.
A lactating woman receives treatment for a medical condition. Which type of medications can the client take to minimize the risk to the neonate? Select all that apply. One, some, or all responses may be correct.
1 Medications that have sustained release Correct 2 Medications that are excluded from milk Correct 3 Medications consumed immediately after breast-feeding Correct 4 Medications that are the least likely to affect the neonate 5 Medications with the lowest effective dose for longer period
The nurse reviews the prescriptions of multiple adolescents with genital herpes simplex infections. Which client's medication regimen would require correction?
1 Client A Correct 2 Client B 3 Client C 4 Client D Valacyclovir, 500 mg orally once a day, is the medication regimen for nonpregnant clients (13-17 years of age) as suppression therapy. Client B's regimen should be changed to once a day. Acyclovir, 400 mg orally tid, would be beneficial in treating primary and recurrent infection in pregnant clients. Client A and Client C, who both have positive pregnancy tests and are taking acyclovir 400 mg orally tid, do not require any corrections to their medication regimens. Valacyclovir, 1 g orally, would be beneficial in treating recurrent infection in nonpregnant clients over 18 years of age. Nonpregnant Client D, who is taking valacyclovir, 1 g orally, does not require any correction to her medication regimen.
Which complication is the pregnant client at risk for related to the dilation of renal pelves and ureters?
1 Frequent urination Correct 2 Urinary tract infection 3 Glomerular filtration rate decreases 4 Increased urinary excretion of protein and albumin
A pregnant woman is found to have low levels of estrogen and is treated with hormonal therapy. The nurse would expect which teratogenic effect to likely occur in the newborn?
1 Goiter 2 Neural tube defects 3 Cleft lip with cleft palate Correct 4 Congenital defects of the female reproductive system
An adolescent client presents to the clinic with complaints of amenorrhea for 2 months. Which would the nurse do next?
1 Help evaluate the adolescent's stress factor. Correct 2 Ask the adolescent to take a pregnancy test. 3 Make a proper dietary and exercise plan with the adolescent. 4 Refer the adolescent to use biofeedback or massage therapy.
In which way is the genital stage different from the phallic stage?
1 In the genital stage, the genital organs are the focus of pleasure. 2 In the genital stage, an individual is influenced by his or her id. Correct 3 In the genital stage, sexual urges are directed outside the family circle. 4 In the genital stage, an individual focuses on the education and social spheres.
Which information regarding sexual intercourse would the nurse give the client with a history of preterm labor who is now 33 weeks' gestation?
1 Intercourse is allowed if penile penetration is not deep. 2 It is permitted unless there is vaginal discomfort. 3 Limit intercourse to once a week to decrease contractions. Correct 4 It should be avoided to prevent stimulation of uterine activity.
A client who has syphilis tells the nurse that it must have been contracted from a toilet seat. The nurse knows that this cannot be true because of which property of the causative agent of syphilis?
1 It is immobilized by body contact. 2 It is chelated by wood and plastic. Correct 3 It is inactivated when exposed to a dry environment. 4 It is destroyed when exposed to a warm environment.
Which statement is true with respect to menarche?
1 It occurs about 6 months after the appearance of breast buds. 2 It occurs approximately 9 months after attainment of peak weight velocity. Correct 3 It occurs approximately 3 months after attainment of peak weight velocity. 4 It occurs approximately 3 months before attainment of peak height velocity.
Which action of the nurse is most appropriate when working with a client who has been sexually assaulted?
1 Monitoring the vital signs and emotional status 2 Asking the client to brush the teeth and take a bath 3 Inquiring about the date of the last tetanus immunization Correct 4 Asking the client to stand on a sheet to remove the clothing
Why is it important for the nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?
1 Most weight gain is caused by fluid retention. Correct 2 Different cultural groups favor different essential nutrients. 3 Dietary allowances should not increase throughout pregnancy. 4 Pregnant women must adhere to a specific pregnancy dietary regimen.
A client who is 38 weeks' pregnant has a nonstress test (NST). The resulting fetal monitor strip is shown. Which interpretation would the nurse assign to this finding?
1 Negative because of the lack of contractions 2 Nonreassuring; fetal heart rate lacks variability Correct 3 Reassuring; fetal heart rate accelerates with movement 4 Positive; demonstrates decelerations with fetal movement The NST is used to compare fetal heart accelerations with fetal movement. This strip shows adequate fetal heart rate variability, and the heart rate accelerates with fetal movement, which is reassuring. Contractions are not a component of an NST. The strip shows adequate fetal heart rate variability, so it is not nonreassuring. A positive NST indicates decelerations of the fetal heart rate with uterine contractions.
Which characteristics would the nurse observe in a client who has secondary amenorrhea?
1 No uterine bleeding for 4 years after breast development Correct 2 Absence of menstrual bleeding for 3 cycles after menarche 3 Absence of uterine bleeding and secondary sex characteristics at age 16 years 4 No uterine bleeding for 1 year after attaining a sexual maturity rating of 5 on the Tanner scale
A woman is being seen in the prenatal clinic at 36 weeks' gestation. Which signs and symptoms by the client require further evaluation by the primary health care provider? Select all that apply. One, some, or all responses may be correct.
Correct 1 Decreased urine output Correct 2 Blurred vision with spots 3 Urinary frequency without dysuria 4 Heartburn after eating a fatty meal Correct 5 Contractions that are regular and 5 minutes apart 6 Shortness of breath after climbing a flight of stairs Decreased urine output, blurred vision, and severe headache may occur with pregnancy-associated hypertension. Contractions that become regular are associated with the onset of labor. Urinary frequency occurs in the first trimester and again in the third trimester as the uterus settles back into the pelvis. The weight of the uterus may delay emptying of the stomach and make heartburn a more frequent problem. Shortness of breath would be expected after the client climbs a flight of stairs.
Clomiphene citrate is prescribed to a client with anovulatory cycles. The nurse would instruct the client to take clomiphene during which part of her cycle?
Correct 1 Fifth day of her cycle 2 Last day of her period 3 Sixteenth day of her cycle 4 Third day after her period begins The objective is to stimulate ovulation near the 14th day of the menstrual cycle, and this is achieved by taking the medication on the 5th through the 9th days; there is an increase in 2 pituitary gonadotropins, luteinizing hormone and follicle-stimulating hormone, with subsequent ovarian stimulation. The last day of her period does not always coincide with day 5 of her cycle. The 16th day of the cycle is also too late for clomiphene to be effective. On the 3rd day after the cycle there are insufficient hormones for clomiphene to be effective.
A medication is administered to a client in her third trimester of pregnancy. Which statement regarding the medication administration is correct?
Correct 1 The dose of a medication should be increased for pregnant clients. 2 No medications should be administered to the pregnant client. 3 Medication dosages should not be altered for a pregnant client. 4 Medication dosage may need to be decreased for pregnant clients. During pregnancy, a client's hepatic metabolism and glomerular filtration are increased. As a result, the excretion rate is faster. The dose of a medication should be increased for the medication action to be optimal. It is true that some medications should not be given to the pregnant client, because of potential teratogenic effects on the fetus. The client should see her health care provider if in doubt. The dose of a medication should be altered for a pregnant client depending on the trimester she is in. How a medication affects the fetus depends on the stage of development of the fetus and the dosage and strength of the medication administered. During the first 3 to 8 weeks after fertilization, the major organs are developing, and the dose of a medication should be decreased or withdrawn for pregnant clients.