High-Risk Antepartum + IPV Olds Maternal Newborn Nursing

A woman suspected of having been raped presents to the emergency room. Which statement, if made by the client, requires the need for further clarification and teaching by the nurse? a. "I didn't have anything to drink and my clothes were modest, so no one could accuse me of leading him on." b. "I thought he was a polite guy who was interested in me. Guess you can't be too careful because a rapist doesn't have any identifying characteristics." c. "I'm going to learn self-defense and fight back next time." d. "Because he just made me have oral sex I wasn't raped."

"Because he just made me have oral sex I wasn't raped." Rationale: Rape is forced sexual intercourse and includes both psychological coercion as well as physical force. It includes vaginal, anal, or oral penetration. Women will be safer if they can defend themselves. A rapist cannot be picked out in a crowd; he doesn't have any particular physical characteristic. Rape is violence and is not caused by alcohol or the type of clothing a woman wears.

Which of the following client statements indicate a need for additional education regarding avoidance of perinatal infection? Select all that apply. a. "If I have beta strep in labor, I will most likely need a C-section." b. "I need to buy a good pair of gloves for when I am working in the garden." c. "After receiving my rubella immunization, I will avoid getting pregnant for 1 month." d. "I will not let the cat sleep in our bed now that I am pregnant."

"If I have beta strep in labor, I will most likely need a C-section." "I will not let the cat sleep in our bed now that I am pregnant." Rationale: GBS requires antibiotic prophylaxis during labor, but a vaginal delivery is not contraindicated. Toxoplasmosis can be transferred in cat feces; clients should be instructed to avoid handling litter boxes. The client should avoid pregnancy for 1 month after receiving the rubella immunization and gardening gloves should be worn during pregnancy to avoid contact with soil organisms. These statements indicate client understanding.

A client, admitted to the emergency room for a broken leg, confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, "Why would he be so cruel to me?" The nurse's best response would be: a. "Men who abuse women are insecure and feel powerless." b. "I bet this is a family trend for you. Were you battered as a child?" c. "I guess you did something to provoke him, and he overreacted." d. "Was your boyfriend drinking? Alcohol causes domestic violence."

"Men who abuse women are insecure and feel powerless." Rationale: Batterers are insecure and feel inferior, powerless, and helpless. They may be jealous and possessive. It is a myth that the woman does anything to provoke the violence, that alcohol causes violence, and that battered women were abused children.

A client comes to the free clinic with multiple bruises on her arms and chest. Her lip is swollen and one of her front teeth is missing. She denies domestic violence and claims to have fallen into the fireplace. Which response by the nurse is most appropriate? a. "I'm sure you did fall into the fireplace. Your injuries are not very life threatening." b. "You'll have no one to blame but yourself if you don't tell us the truth. This will happen again if you return home." c. "These signs are common among women who have been abused. We are trained to assist these women in finding a safe place to escape the abuse." d. "I know you've been abused. No one is fooled. Why not admit it?"

"These signs are common among women who have been abused. We are trained to assist these women in finding a safe place to escape the abuse." Rationale: The nurse should directly confront injuries that appear to be abuse. Gentle encouragement to disclose her situation is appropriate, while accusations and badgering are not.

The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician? 1. Excretion of less than 300 mg of protein in a 24-hour period 2. Platelet count of less than 100,000/mm3 3. Urine output of 50 mL per hour 4. 12 respirations

: 2 Explanation: 2. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 100,000/mm3).

A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what? 1. Sodium 2. Carbohydrates 3. Protein 4. Fruits

: 3 Explanation: 3. The client who experiences preeclampsia is losing protein.

The client describes her male partner's behavior as intimidating and states that she is afraid of him. Which form of intimidation would most likely induce this fear in the client? a. Forbidding her to see her friends. b. The use of religious standards. c. A display of weapons. d. Making negative comments about her.

A display of weapons. Rationale: Psychologic abuse takes many forms. Intimidation is often achieved by displaying weapons. The abuser may use others or religion to enforce control. Forbidding her to see friends is a form of isolation. Making negative personal comments is emotional abuse.

A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority? 1. Fluid Volume: Deficient 2. Cardiac Output, Decreased 3. Injury, Risk for 4. Nutrition, Imbalanced: Less than Body Requirements

Answer: 1 Explanation: 1. The newly admitted client with hyperemesis gravidarum has been experiencing excessive vomiting, and is in a fluid volume-deficit state.

The nurse researcher is gathering data about the types of rape. She is interviewing clients who were recently raped. A 65-year-old woman describes her rapist as extremely violent. She states that the rapist continually screamed, "This is what you get." The nurse researcher classifies this type of rape as: a. Anger rape. b. Sadistic rape. c. Acquaintance rape. d. Stranger rape.

Anger rape. Rationale: An anger rape expresses rage for perceived wrongs committed against the rapist. A sadistic rape is characterized by torture and mutilation. The stranger rape is likely to include the use of weapons. An acquaintance rape is carried out by an individual with whom the victim has had previous contact.

A primary herpes simplex infection in the first trimester can increase the risk of which of the following? 1. Spontaneous abortion 2. Preterm labor 3. Intrauterine growth restriction 4. Neonatal infection

Answer: 1 Explanation: 1. A primary herpes simplex infection can increase the risk of spontaneous abortion when infection occurs in the first trimester.

A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the client understands that what is essential? 1. That she not become pregnant until after the follow-up program is completed 2. That she receive RhoGAM with her next pregnancy and birth 3. That she has her blood pressure checked weekly for the next 30 days 4. That she seek genetic counseling with her partner before the next pregnancy

Answer: 1 Explanation: 1. Because of the risk of choriocarcinoma, the woman treated for hydatidiform mole should receive extensive follow-up therapy. Follow-up care includes a baseline chest X-ray to detect lung metastasis and a physical examination including a pelvic examination. The woman should avoid pregnancy during this time because the elevated hCG levels associated with pregnancy would cause confusion as to whether cancer had developed.

During a prenatal exam, a client describes several psychosomatic symptoms and has several vague complaints. What could these behaviors indicate? 1. Abuse 2. Mental illness 3. Depression 4. Nothing, they are normal

Answer: 1 Explanation: 1. Chronic psychosomatic symptoms and vague complaints can be indicators of abuse.

Doppler flow studies (umbilical velocimetry) help to assess which of the following? 1. Placental function and sufficiency 2. Fetal heart rate 3. Fetal growth and fluid levels 4. Maturity of the fetal lungs

Answer: 1 Explanation: 1. Doppler flow studies (umbilical velocimetry) help to assess placental function and sufficiency. Uteroplacental insufficiency is a risk for a woman with preeclampsia. If fetal growth restriction is present, Doppler velocimetry of the umbilical artery is useful for fetal surveillance.

A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity? 1. Patellar reflexes weak or absent 2. Increased appetite 3. Respiratory rate of 16 4. Fetal heart rate of 120

Answer: 1 Explanation: 1. Early signs of magnesium sulfate toxicity are related to a decrease in deep tendon reflexes.

The nurse is caring for a pregnant woman who admits to using cocaine and ecstasy on a regular basis. The client states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal about ecstasy?" What is the nurse's best response? 1. "Ecstasy can cause a high fever in you and therefore cause the baby harm." 2. "Ecstasy leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "Ecstasy produces babies with small heads and short bodies with brain function alterations." 4. "Ecstasy produces intrauterine growth restriction and meconium aspiration."

Answer: 1 Explanation: 1. Hyperthermia (elevated temperature) is a side effect of MDMA (ecstasy).

A woman's history and appearance suggest drug abuse. What is the nurse's best approach? 1. Ask the woman directly, "Do you use any street drugs?" 2. Ask the woman whether she would like to talk to a counselor. 3. Ask some questions about over-the-counter medications and avoid mention of illicit drugs. 4. Explain how harmful drugs can be for her baby.

Answer: 1 Explanation: 1. If drug abuse is suspected, the nurse should ask direct questions and be matter-of-fact and nonjudgmental to elicit honest responses.

Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of which condition? 1. Intrauterine growth restriction 2. Oliguria 3. Proteinuria 4. Hypertension

Answer: 1 Explanation: 1. Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of intrauterine growth restriction. The cause is related specifically to maternal vasospasm and hypovolemia, which result in fetal hypoxia and malnutrition.

The client with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client? 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. Vascular disease that accompanies diabetes slows progression. 4. The baby is likely to have a congenital abnormality because of the diabetes.

Answer: 1 Explanation: 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase.

The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective? 1. "I need to get RhoGAM so I don't have problems with my next pregnancy." 2. "Because my baby is Rh-positive, I don't need RhoGAM." 3. "If my baby had the same blood type I do, it might cause complications." 4. "Before my next pregnancy, I will need to have a RhoGAM shot."

Answer: 1 Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization.

The prenatal clinic nurse has received four phone calls. Which client should the nurse call back first? 1. Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing and shortness of breath 2. Pregnant woman at 6 weeks with a seizure disorder who is inquiring which foods are good folic acid sources for her 3. Pregnant woman at 35 weeks with a positive HBsAG who is wondering what treatment her baby will receive after birth 4. Pregnant woman at 11 weeks with untreated hyperthyroidism who is describing the onset of vaginal bleeding

Answer: 1 Explanation: 1. The goal of therapy is to prevent maternal exacerbations because even a mild exacerbation can cause severe hypoxia-related complications in the fetus.

) A client is concerned because she has been told her blood type and her baby's are incompatible. What is the nurse's best response? 1. "This is called ABO incompatibility. It is somewhat common but rarely causes significant hemolysis." 2. "This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy." 3. "This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby." 4. "This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring."

Answer: 1 Explanation: 1. When blood types, not Rh, are incompatible, it is called ABO incompatibility. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal RBCs.

A client with diabetes is receiving preconception counseling. The nurse will emphasize that during the first trimester, the woman should be prepared for which of the following? 1. The need for less insulin than she normally uses 2. Blood testing for anemia 3. Assessment for respiratory complications 4. Assessment for contagious conditions

Answer: 1 Explanation: 1. Women with diabetes often require less insulin during the first trimester.

A pregnant asthmatic client is being seen for her initial prenatal visit. The nurse knows that the fetal implications of maternal asthma include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Prematurity 2. Low birth weight 3. Hypoxia with maternal exacerbation 4. Congenital anomalies from the medications 5. Perinatal transfer of the asthma

Answer: 1, 2, 3 Explanation: 1. One implication of maternal asthma is that the infant is at risk for prematurity. 2. One implication of maternal asthma is that the infant is at risk for low birth weight. 3. One implication of maternal asthma is that the infant is at risk for hypoxia if the mother has an exacerbation of her asthma.

The nurse is working with a pregnant woman who has systemic lupus erythematosus (SLE). What does the nurse anticipate the infant might be born with? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. A tendency to bleed excessively 2. An increased chance of developing infections 3. A hemoglobin less than optimal for good health 4. Problems with vision 5. Hearing loss

Answer: 1, 2, 3 Explanation: 1. This is true, as the infant might be born with thrombocytopenia. 2. This is true, as the infant might be born with neutropenia. 3. This is true, as the infant might be born with anemia.

The nurse is working with a woman who abuses stimulants. The nurse is aware that the fetus is at risk for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Withdrawal symptoms 2. Cardiac anomalies 3. Sudden infant death syndrome 4. Being small for gestational age 5. Fetal alcohol syndrome

Answer: 1, 2, 3, 4 Explanation: 1. Infants born to mothers who abuse stimulants such as amphetamines can have withdrawal symptoms. 2. Infants born to mothers who abuse stimulants such as cocaine can be born with cardiac anomalies. 3. Infants born to mothers who abuse stimulants such as cocaine can have sudden infant death syndrome. 4. Infants born to mothers who abuse stimulants such as nicotine can be small for gestational age.

The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Prematurity 2. Maternal intrapartum fever 3. Membranes ruptured for longer than 18 hours 4. A previously infected infant with GBS disease 5. An older mother having her first baby

Answer: 1, 2, 3, 4 Explanation: 1. Prematurity is a risk factor. 2. Maternal intrapartum fever is a risk factor. 3. Prolonged rupture of membranes is a risk factor. 4. A previously infected infant increases the risk.

The nurse educator is presenting a class on the different kinds of miscarriages. Miscarriages, or spontaneous abortions, are classified clinically into which of the following different categories? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Threatened abortion 2. Incomplete abortion 3. Complete abortion 4. Missed abortion 5. Acute abortion

Answer: 1, 2, 3, 4 Explanation: 1. Unexplained cramping, bleeding, or backache indicates the fetus might be in jeopardy. This is a threatened abortion. 2. In an incomplete abortion, parts of the products of conception are retained, most often the placenta. 3. In a complete abortion, all the products of conception are expelled. The uterus is contracted and the cervical os may be closed. 4. In a missed abortion, the fetus dies in utero but is not expelled.

When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal heart rate 2. Blood pressure 3. Temperature 4. Urine color 5. Pulse and respirations

Answer: 1, 2, 3, 5 Explanation: 1. Determine the fetal heart rate along with blood pressure, or monitor continuously with the electronic fetal monitor if the situation indicates. 2. Determine blood pressure every 1 to 4 hours, or more frequently if indicated by medication or other changes in the woman's status. 3. Determine temperature every 4 hours, or every 2 hours if elevated or if premature rupture of the membranes (PROM) has occurred. 5. Determine pulse rate and respirations along with blood pressure.

A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant client. When should the first dose of RhoGAM be administered? 1. After the birth of the infant 2. 1 month postpartum 3. During labor 4. At 28 weeks' gestation

Answer: 4 Explanation: 4. When the woman is Rh negative and not sensitized and the father is Rh positive or unknown, Rh immune globulin is given prophylactically at 28 weeks' gestation.

Which of the following symptoms, if progressive, are indicative of CHF, the heart's signal of its decreased ability to meet the demands of pregnancy? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Palpitations 2. Heart murmurs 3. Dyspnea 4. Frequent urination 5. Rales

Answer: 1, 2, 3, 5 Explanation: 1. Palpitations are indicative of CHF. 2. Heart murmurs are indicative of CHF. 3. Dyspnea is indicative of CHF. 5. Rales are indicative of CHF.

The nurse has written the nursing diagnosis Injury, Risk for for a diabetic pregnant client. Interventions for this diagnosis include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Assessment of fetal heart tones 2. Perform oxytocin challenge test, if ordered 3. Refer the client to a diabetes support group 4. Assist with the biophysical profile assessment 5. Develop an appropriate teaching plan

Answer: 1, 2, 4 Explanation: 1. Reassuring fetal heart rate variability and accelerations are interpreted as adequate placental oxygenation. 2. The nurse would perform oxytocin challenge test (OCT)/contraction stress test (CST) and non-stress tests as determined by physician. 4. The nurse assists the physician in performing a biophysical profile assessment.

The nurse is presenting a class on the pathophysiology of the different abortions. Some of the causes are which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Chromosomal abnormalities 2. Insufficient or excessive hormonal levels 3. Sexual intercourse in the first trimester 4. Infections in the first trimester 5. Cervical insufficiency

Answer: 1, 2, 4, 5 Explanation: 1. Chromosomal defects are generally seen as spontaneous abortions during weeks 4 to 8. 2. Insufficient or excessive hormonal levels usually will result in spontaneous abortion by 10 weeks' gestation. 4. Infectious and environmental factors may also be seen in first trimester pregnancy loss. 5. In late spontaneous abortion, the cause is usually a maternal factor, for example, cervical insufficiency or maternal disease, and fetal death may not precede the onset of abortion.

The nurse is evaluating the plan of care for a pregnant client with a heart disorder. The nurse concludes that the plan was successful when data indicate which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. The client gave birth to a healthy baby. 2. The client did not develop congestive heart failure. 3. The client developed thromboembolism. 4. The client identified manifestations of potential complications. 5. The client can identify her condition and its impact on her pregnancy, labor and birth, and postpartum period.

Answer: 1, 2, 4, 5 Explanation: 1. Giving birth to a healthy baby is an expected outcome of the pregnancy. 2. An expected outcome is that the woman does not develop congestive heart failure, thromboembolism, or infection. 4. An expected outcome is that the woman is able to identify potential complications and notify the healthcare provider. 5. The woman must be able to discuss her condition and its possible impact on her pregnancy, labor and birth, and the postpartum period.

During the history, the client admits to being HIV-positive and says she knows that she is about 16 weeks pregnant. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "During labor and delivery, I can expect the zidovudine (ZDV) to be given in my IV." 2. "After delivery, the dose of zidovudine (ZDV) will be doubled to prevent further infection." 3. "My baby will be started on zidovudine (ZDV) for six weeks following the birth." 4. "My baby's zidovudine (ZDV) will be given in a cream form." 5. "My baby will not need zidovudine (ZDV) if I take it during my pregnancy."

Answer: 1, 3 Explanation: 1. ART therapy generally it includes oral Zidovudine (ZDV) daily, IV ZDV during labor and until birth, and ZDV therapy for the infant for 6 weeks following birth. 3. ART therapy generally it includes oral Zidovudine (ZDV) daily, IV ZDV during labor and until birth, and ZDV therapy for the infant for 6 weeks following birth.

The client at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the client understands the treatment being administered? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "The baby needs to be monitored to check the heart rate." 2. "My bowel has probably been lacerated by the knife." 3. "I might need an ultrasound to look at the baby." 4. "The catheter in my bladder will prevent urinary complications." 5. "The IV in my arm will replace the amniotic fluid if it is leaking."

Answer: 1, 3 Explanation: 1. Ongoing assessments of trauma include evaluation of uterine tone, contractions and tenderness, fundal height, fetal heart rate, intake and output and other indicators of shock, normal postoperative evaluation in those women requiring surgery, determination of neurologic status, and assessment of mental outlook and anxiety level. 3. In cases of noncatastrophic trauma, where the mother's life is not directly threatened, fetal monitoring for 4 hours should be sufficient if there is no vaginal bleeding, uterine tenderness, contractions, or leaking amniotic fluid.

A client at 18 weeks' gestation has been diagnosed with a hydatidiform mole. In addition to vaginal bleeding, which signs or symptoms would the nurse expect to see? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperemesis gravidarum 2. Diarrhea and hyperthermia 3. Uterine enlargement greater than expected 4. Polydipsia 5. Vaginal bleeding

Answer: 1, 3, 5 Explanation: 1. This is often seen in clients with hydatidiform mole. 3. This is a classic sign of hydatidiform mole. 5. This is a classic symptom of hydatidiform mole.

A client is admitted to the labor suite. It is essential that the nurse assess the woman's status in relation to which infectious diseases? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Chlamydia trachomatis 2. Rubeola 3. Varicella 4. Group B streptococcus 5. Acute pyelonephritis

Answer: 1, 4, 5 Explanation: 1. The infant may develop chlamydial pneumonia and Chlamydia trachomatis may be responsible for premature labor and fetal death. Chlamydial infection should be assessed. 4. Women may transmit GBS to their fetus in utero or during childbirth. GBS is a leading infectious cause of neonatal sepsis and mortality and should be assessed. 5. Acute pyelonephritis should be assessed as there is an increased risk of premature birth and intrauterine growth restriction (IUGR).

A newly diagnosed insulin-dependent type 1 diabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. What would the best explanation include? 1. "Your baby could be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "As long as you control your blood sugar, your baby will not be affected at all." 4. "Your baby might have high blood sugar for several days."

Answer: 2 Explanation: 2. Characteristically, infants of mothers with diabetes are large for gestational age (LGA) as a result of high levels of fetal insulin production stimulated by the high levels of glucose crossing the placenta from the mother. Sustained fetal hyperinsulinism and hyperglycemia ultimately lead to excessive growth, called macrosomia, and deposition of fat.

The nurse is assessing a woman at 10 weeks' gestation who is addicted to alcohol. The woman asks the nurse, "What is the point of stopping drinking now if my baby probably has been hurt by it already?" What is the best response by the nurse? 1. "It won't help your baby, but you will feel better during your pregnancy if you stop now." 2. "If you stop now, you and your baby have less chance of serious complications." 3. "If you limit your drinking to once a week, your baby will be okay." 4. "You might as well stop it now, because once your baby is born, you'll have to give up alcohol if you plan on breastfeeding."

Answer: 2 Explanation: 2. Chronic abuse of alcohol can undermine maternal health by causing malnutrition, bone marrow suppression, increased incidence of infections, and liver disease. The effects of alcohol on the fetus may result in fetal alcohol spectrum disorders (FASD).

The client at 9 weeks' gestation has been told that her HIV test was positive. The client is very upset, and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the client makes which statement? 1. "I cannot take the medications that control HIV during my pregnancy, because they will harm the baby." 2. "My baby can get HIV during the pregnancy and through my breast milk." 3. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 4. "The HIV won't affect my baby, and I will have a low-risk pregnancy without additional testing."

Answer: 2 Explanation: 2. HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth.

A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. What should the nurse's response be? 1. "Heparin is used when coagulation problems are resolved." 2. "Heparin is safer because it does not cross the placenta." 3. "They are the same drug, but heparin is less expensive." 4. "Coumadin interferes with iron absorption in the intestines."

Answer: 2 Explanation: 2. Heparin is safest for the client to take because it does not cross the placental barrier.

A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, what should the nurse also say? 1. "Your baby will be fine. We'll start IV, and get this stopped in no time at all." 2. "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." 3. "You are going to miscarry. But you should be relieved because most miscarriages are the result of abnormalities in the fetus." 4. "I really can't say. However, when your physician comes, I'll ask her to talk to you about it."

Answer: 2 Explanation: 2. If bleeding persists and abortion is imminent or incomplete, the woman may be hospitalized, IV therapy or blood transfusions may be started to replace fluid, and dilation and curettage (D&C) or suction evacuation is performed to remove the remainder of the products of conception.

The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Entrance wound present below the umbilicus." 3. "Client is positioned in a left lateral tilt." 4. "Clear fluid is leaking from the vagina."

Answer: 2 Explanation: 2. Penetrating trauma includes gunshot wounds and stab wounds. The mother generally fares better than the fetus if the penetrating trauma involves the abdomen as the enlarged uterus is likely to protect the mother's bowel from injury.

A client at 10 weeks' gestation has developed cholecystitis. If surgery is required, what is the safest time during pregnancy? 1. Immediately, before the fetus gets any bigger 2. Early in the second trimester 3. As close to term as possible 4. The risks are too high to do it anytime in pregnancy

Answer: 2 Explanation: 2. The early second trimester is the best time to operate because there is less risk of spontaneous abortion or early labor, and the uterus is not so large as to impinge on the abdominal field.

A 26-year-old client is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client? 1. "Exercise either just before meals or wait until 2 hours after a meal." 2. "Carry hard candy (or other simple sugar) when exercising." 3. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." 4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk."

Answer: 2 Explanation: 2. The nurse should advise her to carry a simple sugar such as hard candy because of the possibility of exercise-induced hypoglycemia.

The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Give 1 liter of lactated Ringer's solution IV. 3. Administer 30 mL Maalox (magnesium hydroxide) orally. 4. Encourage clear liquids orally.

Answer: 2 Explanation: 2. The vital signs indicate hypovolemia from dehydration, which leads to hypotension and increased pulse rate. Giving this client a liter of lactated Ringer's solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.

A woman is 32 weeks pregnant. She is HIV-positive but asymptomatic. The nurse knows what would be important in managing her pregnancy and delivery? 1. An amniocentesis at 30 and 36 weeks 2. Weekly non-stress testing beginning at 32 weeks' gestation 3. Application of a fetal scalp electrode as soon as her membranes rupture in labor 4. Administration of intravenous antibiotics during labor and delivery

Answer: 2 Explanation: 2. Weekly non-stress testing (NST) is begun at 32 weeks' gestation and serial ultrasounds are done to detect IUGR.

The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which statement made by the client indicates to the nurse that the client has understood the teaching? 1. "I can continue to drink alcohol until I am diagnosed as pregnant." 2. "I need to stop drinking alcohol completely when I start trying to get pregnant." 3. "A beer once a week will not damage the fetus." 4. "I can drink alcohol while breastfeeding because it doesn't pass into breast milk."

Answer: 2 Explanation: 2. Women should discontinue drinking alcohol when they start to attempt to become pregnant due to possible effects of alcohol on the fetus.

Women with HIV should be evaluated and treated for other sexually transmitted infections and for what condition occurring more commonly in women with HIV? 1. Syphilis 2. Toxoplasmosis 3. Gonorrhea 4. Herpes

Answer: 2 Explanation: 2. Women with HIV should be evaluated and treated for other sexually transmitted infections and for conditions occurring more commonly in women with HIV, such as tuberculosis, cytomegalovirus, toxoplasmosis, and cervical dysplasia.

) The client presents to the clinic for an initial prenatal examination. She asks the nurse whether there might be a problem for her baby because she has type B Rh-positive blood and her husband has type O Rh-negative blood, or because her sister's baby had ABO incompatibility. What is the nurse's best answer? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Your baby would be at risk for Rh problems if your husband were Rh-negative." 2. "Rh problems only occur when the mother is Rh-negative and the father is not." 3. "ABO incompatibility occurs only after the baby is born." 4. "We don't know for sure, but we can test for ABO incompatibility." 5. "Your husband's being type B puts you at risk for ABO incompatibility."

Answer: 2, 3 Explanation: 2. Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive. 3. ABO incompatibility is limited to type O mothers with a type A or B fetus and occurs after the baby is born.

The clinic nurse is teaching a pregnant client about her iron supplement. Which information is included in the teaching? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Iron does not affect the gastrointestinal tract. 2. A stool softener might be needed. 3. Start a low dose, and increase it gradually. 4. Expect the stools to be black and bloody. 5. Iron absorption is poor if taken with meals.

Answer: 2, 3, 5 Explanation: 2. Constipation can be a problem when taking iron, so a stool softener might be needed. 3. To prevent anemia, experts recommend that all pregnant women start on 30 mg/day of iron supplements daily. If anemia is diagnosed, the dosage should be increased to 60 to 120 mg per day of iron. 5. Iron absorption is reduced by 40% to 50% if taken with meals.

The nurse is evaluating the goal "Client will remain free of opportunistic infections" for an HIV-positive pregnant client. The nurse determines the goal was met when the client has which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. An absolute CD4+ T-lymphocyte count below 200 2. No complaint of chills or fever during the pregnancy 3. Weight gain of 30 lbs during the pregnancy 4. ESR above 20 mm/hr 5. Normal erythrocyte sedimentation rate maintained during the pregnancy

Answer: 2, 3, 5 Explanation: 2. Not having chills, fever, or a sore throat throughout the pregnancy is an indication the client did not have an infection. 3. Weight gain of 25 to 35 pounds is normal for a pregnancy. This client met the goal for nutrition and remaining infection-free. 5. Having a normal erythrocyte sedimentation rate during the pregnancy is an expected outcome.

A client is being admitted to the labor area with the diagnosis of eclampsia. Which actions by the nurse are appropriate at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails. 3. Have the woman sit up. 4. Provide the client with grief counseling. 5. The airway should be maintained and oxygen administered.

Answer: 2, 5 Explanation: 2. Side rails should be up and padded. 5. Suctioning may be necessary to keep the airway clear.

A pregnant client has been admitted with a diagnosis of hyperemesis. Which orders written by the primary healthcare provider are the highest priorities for the nurse to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Obtain complete blood count. 2. Start intravenous fluid with multivitamins. 3. Check admission weight. 4. Obtain urine for urinalysis. 5. Give a medication to stop the nausea and vomiting.

Answer: 2, 5 Explanation: 2. Starting intravenous fluid with multivitamins is a priority if the client has been vomiting. 5. Giving a medication to stop the nausea and vomiting is a priority.

Whether sensitization is the result of a blood transfusion or maternal-fetal hemorrhage for any reason, what test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed? 1. Indirect Coombs' test 2. Nonstress test 3. Kleihauer-Betke or rosette test 4. Direct Coombs' test

Answer: 3 Explanation: 3. A Kleihauer-Betke or rosette test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed.

A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response? 1. "This medication will halt the labor process until the baby is more mature." 2. "This medication will relax the smooth muscles in the infant's lungs so the baby can breathe." 3. "This medication is effective in stimulating lung development in the preterm infant." 4. "This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor."

Answer: 3 Explanation: 3. Betamethasone or dexamethasone is often administered to the woman whose fetus has an immature lung profile to promote fetal lung maturation.

The nurse is supervising care in the emergency department. Which situation most requires an intervention? 1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour 3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports an absence of fetal movement

Answer: 3 Explanation: 3. Bleeding in the third trimester is usually a placenta previa or placental abruption. Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness. Monitor vital signs, particularly blood pressure and pulse, for evidence of developing shock.

Which maternal-child client should the nurse see first? 1. Blood type O, Rh-negative 2. Indirect Coombs' test negative 3. Direct Coombs' test positive 4. Blood type B, Rh-positive

Answer: 3 Explanation: 3. Direct Coombs' test is done on the infant's blood to detect antibody-coated Rh-positive RBCs. If the mother's indirect Coombs' test is positive and her Rh-positive infant has a positive direct Coombs' test, Rh immune globulin is not given; in this case, the infant is carefully monitored for hemolytic disease.

If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent what? 1. The potential for hemorrhage 2. Hyperhomocysteinemia 3. Antibody formation 4. Tubal pregnancy

Answer: 3 Explanation: 3. If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent antibody formation.

The community nurse is working with a client at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the client would indicate that additional information is needed? 1. "I should call the doctor if I develop a headache or blurred vision." 2. "Lying on my left side as much as possible is good for the baby." 3. "My urine could become darker and smaller in amount each day." 4. "Pain in the top of my abdomen is a sign my condition is worsening."

Answer: 3 Explanation: 3. Oliguria is a complication of preeclampsia. Specific gravity of urine readings over 1.040 correlate with oliguria and proteinuria and should be reported to the physician.

A woman asks her nurse what she can do before she begins trying to get pregnant to help her baby, as she is prone to anemia. What would the nurse correctly advise her to do? 1. Get pregnant, then start iron supplementation. 2. Add more carbohydrates to her diet. 3. Begin taking folic acid supplements daily. 4. Have a hemoglobin baseline done now so her progress can be followed.

Answer: 3 Explanation: 3. The common anemias of pregnancy are due either to insufficient hemoglobin production related to nutritional deficiency in iron or folic acid during pregnancy. Folic acid deficiency during pregnancy is prevented by a daily supplement of 0.4 mg (400 micrograms) of folate.

A 21-year-old at 12 weeks' gestation with her first baby has known cardiac disease, class III, as a result of childhood rheumatic fever. During a prenatal visit, the nurse reviews the signs of cardiac decompensation with her. The nurse will know that the client understands these signs and symptoms if she states that she would notify her doctor if she had which symptom? 1. "A pulse rate increase of 10 beats per minute" 2. "Breast tenderness" 3. "Mild ankle edema" 4. "A frequent cough"

Answer: 4 Explanation: 4. The heart's signal of its decreased ability to meet the demands of pregnancy includes frequent cough (with or without hemoptysis).

A client who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain. Laboratory tests reveal a beta-hCG at a lower-than-expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The client is crying and asks what is happening. The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include? 1. "You're feeling dizzy because the pregnancy is compressing your vena cava." 2. "The pain is due to the baby putting pressure on nerves internally." 3. "The baby is in the fallopian tube; the tube has ruptured and is causing bleeding." 4. "This is a minor problem. The doctor will be right back to explain it to you."

Answer: 3 Explanation: 3. The woman who experiences one-sided lower abdominal pain or diffused lower abdominal pain, vasomotor disturbances such as fainting or dizziness, and referred right shoulder pain from blood irritating the subdiaphragmatic phrenic nerve is experiencing an ectopic pregnancy.

A diabetic client goes into labor at 36 weeks' gestation. Provided that tests for fetal lung maturity are successful, the nurse will anticipate which of the following interventions? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Administration of tocolytic therapy 2. Beta-sympathomimetic administration 3. Allowance of labor to progress 4. Hourly blood glucose monitoring 5. Cesarean birth may be indicated if evidence of reassuring fetal status exists

Answer: 3, 4 Explanation: 3. There will be no attempt to stop the labor, as this can compromise the mother and fetus. 4. To reduce incidence of congenital anomalies and other problems in the newborn, the woman should be euglycemic (have normal blood glucose) throughout the pregnancy.

The nurse is presenting a class to newly pregnant families. What form of trauma will the nurse describe as the leading cause of fetal and maternal death? 1. Falls 2. Domestic violence 3. Gun accidents 4. Motor vehicle accidents

Answer: 4 Explanation: 4. Trauma from motor vehicle accidents is the leading cause of fetal and maternal death.

The client at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The client's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the client? 1. "Your low iron intake has caused anemia, which leads to the neural tube defect." 2. "You should increase your vitamin C intake to improve your anemia." 3. "You are too picky about food. Your poor diet caused your baby's defect." 4. "You haven't had enough folic acid in your diet. You should take a supplement."

Answer: 4 Explanation: 4. An inadequate intake of folic acid has been associated with neural tube defects (NTDs) (e.g., spina bifida, anencephaly, meningomyelocele) in the fetus or newborn.

The client with thalassemia intermedia has a hemoglobin level of 9.0. The nurse is preparing an education session for the client. Which statement should the nurse include? 1. "You need to increase your intake of meat and other iron-rich foods." 2. "Your low hemoglobin could put you into preterm labor." 3. "Increasing your vitamin C intake will help your hemoglobin level." 4. "You should not take iron supplements."

Answer: 4 Explanation: 4. Folic acid supplements are indicated for women with thalassemia, but iron supplements are not given.

A 26-year-old client is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? 1. A 50g, 1-hour glucose screening test 2. A single fasting glucose level 3. A 100g, 1-hour glucose tolerance test 4. A 100g, 3-hour glucose tolerance test

Answer: 4 Explanation: 4. Gestational diabetes is diagnosed if two or more of the following values are met or exceeded after taking the 100 g, 3-hour OGTT: Fasting: 95 mg/dL; 1 hour: 180 mg/dL; 2 hours: 155 mg/dL; 3 hours: 140 mg/dL.

While doing a prenatal assessment on a woman who has hepatitis B and intends to become pregnant, the nurse explains the impact of the hepatitis B on pregnancy and birth. Which statement does the nurse include in the teaching? 1. "Your baby contracted hepatitis B from you when she was conceived." 2. "Don't worry about your baby during the birth. You're more likely to be affected then by the hepatitis B." 3. "Your baby will be immune to your hepatitis B." 4. "Hepatitis B does not usually affect the course of pregnancy."

Answer: 4 Explanation: 4. Hepatitis B does not usually affect the course of pregnancy.

A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the client needs to be retested for HIV? 1. Hemoglobin of 11 g/dL and a rapid weight gain 2. Elevated blood pressure and ankle edema 3. Shortness of breath and frequent urination 4. Persistent candidiasis

Answer: 4 Explanation: 4. Signs and symptoms of infections include fever, weight loss, fatigue, persistent candidiasis, diarrhea, cough, and skin lesions (Kaposi's sarcoma and hairy leukoplakia in the mouth).

The client has just been diagnosed as diabetic. The nurse knows teaching was effective when the client makes which statement? 1. "Ketones in my urine mean that my body is using the glucose appropriately." 2. "I should be urinating frequently and in large amounts to get rid of the extra sugar." 3. "My pancreas is making enough insulin, but my body isn't using it correctly." 4. "I might be hungry frequently because the sugar isn't getting into the tissues the way it should."

Answer: 4 Explanation: 4. The client who understands the disease process is aware that if the body is not getting the glucose it needs, the message of hunger will be sent to the brain.

A 21-year-old woman is at 12 weeks' gestation with her first baby. She has cardiac disease, class III, as a result of having had childhood rheumatic fever. Which planned activity would indicate to the nurse that the client needs further teaching? 1. "I will be sure to take a rest period every afternoon." 2. "I would like to take childbirth education classes in my last trimester." 3. "I will have to cancel our trip to Disney World." 4. "I am going to start my classes in water aerobics next week."

Answer: 4 Explanation: 4. With the slightest exertion, the client's heart rate will rise, and she will become symptomatic. Therefore, she should not establish a new exercise program.

A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for which condition? 1. Erythroblastosis fetalis 2. Diabetes mellitus 3. Abruptio placentae 4. Pregnancy-induced hypertension

Answer: 4 Explanation: 4. Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or preeclampsia-eclampsia).

The nurse is caring for a client who was just admitted to rule out ectopic pregnancy. Which orders are the most important for the nurse to perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Report complaints of dizziness or weakness. 5. Have the lab draw blood for B-hCG level every 48 hours.

Answer: 4, 5 Explanation: 4. Reporting complaints of dizziness and weakness is important, as it can indicate hypovolemia from internal bleeding. 5. Having the lab draw blood for B-hCG levels every 48 hours is important, as the level rises much more slowly in ectopic pregnancy than in normal pregnancy.

The nurse is completing a history for a new client in the prenatal clinic. The client states that she had a ventricular septal defect successfully repaired with no further problems. The nurse anticipates what order for this client? a. Sodium restriction. b. Diuretics and strict bed rest. c. Antibiotic prophylaxis. d. Anticoagulant therapy.

Antibiotic prophylaxis. Rationale: Because of the risk of subacute bacterial endocarditis, even in cases where the heart defect was corrected surgically, antibiotic prophylaxis is often recommended at the time of birth. Treatment for peripartum cardiomyopathy (not cardiac defects) includes digoxin, diuretics, vasodilators as necessary, anticoagulants, sodium restriction, and strict bedrest.

A client at 30 weeks' gestation is admitted to the maternity unit with vaginal bleeding. What should be the nurse's initial nursing action? a. Count and weigh peripads. b. Start an intravenous infusion drip. c. Assess blood pressure and pulse. d. Observe for pallor, clammy skin, and perspiration.

Assess blood pressure and pulse. Rationale: The nurse's initial action for a client with vaginal bleeding at 30 weeks would be to assess blood pressure and pulse. Counting and weighing peripads; observing for pallor, clammy skin, and perspiration; and starting an intravenous infusion drip are all important actions for this client; they are just not the initial action.

A prenatal client with insulin-dependent diabetes asks the nurse about pregnancy-related complications from diabetes for her baby. The nurse responds that the baby is at risk for which of the following when the mother has insulin-dependent diabetes? Select all that apply. a. Congenital anomalies. b. Macrosomia. c. Respiratory distress syndrome. d. Hyperactivity.

Congenital anomalies. Macrosomia. Respiratory distress syndrome. Rationale: The infant of a diabetic mother is at risk for congenital anomalies, respiratory distress, and macrosomia. Hyperactivity is not a risk factor for a newborn whose mother has diabetes.

A postpartum client who admits to heavy alcohol use asks the nurse about breastfeeding her baby. The nurse correctly teaches this client that excessive alcohol consumption while breastfeeding can: a. Cause mental retardation in the newborn. b. Decrease the maternal milk letdown reflex. c. Increase the maternal letdown reflex. d. Cause seizure disorders in the newborn.

Decrease the maternal milk letdown reflex. Rationale: Excessive alcohol consumption while breastfeeding can decrease, not increase, the maternal milk ejection reflex. Fetuses exposed to heroin in utero can experience seizure disorders as newborns. Mental abnormalities in the newborn can result from alcohol exposure in utero, not through consumption of breast milk.

During a prenatal visit, a client states, "Sometimes my boyfriend hits me, but it is just when he is stressed at work. I know he loves the baby and me; it's just hard right now. He wouldn't really hurt me." The nurse's first priority is to: a. Notify the social worker immediately. b. Determine the client's immediate safety. c. Encourage the client to leave her partner as soon as possible for the sake of the baby. d. Give the client pamphlets with the contact information for local shelters.

Determine the client's immediate safety. Rationale: Answer (c) is correct; when working with clients who are victims of physical abuse, the priority is always to determine the client's immediate safety. Answer (a) is incorrect; notifying a social worker is an appropriate action but it is not the immediate priority. Answer (b) is incorrect; giving information to victims of abuse must be discreet; if the abuser feels the client may leave, the violence may escalate. Answer (d) is incorrect; there are numerous factors associated with deciding to leave an abusive relationship; it is seldom a rapid or easy process. The nurse's role is to support the client in developing the best safety plan.

The nurse is caring for a laboring client with Type I diabetes. What are the signs and symptoms of hypoglycemia for which the nurse should assess? a. Frequent urination and headache. b. Headache and anorexia. c. Dry skin and blurred vision. d. Diaphoresis and disorientation.

Diaphoresis and disorientation. Rationale: Hypoglycemia manifests itself during labor in a Type I diabetic with diaphoresis and disorientation. There is usually hunger and decreased urination, with headache, clammy skin, and blurred vision.

A client presents to the physician's office with complaints of right-sided abdominal pain, dizziness, and vaginal bleeding. A pelvic exam determines adnexal tenderness. What diagnosis should the nurse suspect? a. Cholelithiasis. b. Appendicitis. c. Threatened abortion. d. Ectopic pregnancy.

Ectopic pregnancy. Rationale: A client with an ectopic pregnancy would present to the physician's office with complaints of one-sided abdominal pain, dizziness, and vaginal bleeding, and would have adnexal tenderness on exam. Clients with a threatened abortion would have complaints of unexplained bleeding, cramping, or backache. A pelvic exam would reveal a closed cervix. Clients with appendicitis would have complaints of lower right-sided tenderness, low-grade fever, nausea, and often vomiting. Clients with cholelithiasis would have complaints of epigastric distress, such as fullness, distention, and vague pain in the right upper quadrant of the abdomen.

A 12-year-old girl presents to the emergency room and reports being raped by her stepfather. The emergency room nurse knows that the chain of evidence must be preserved. What are the uses of the evidence that the nurse collects? Select all that apply. a. Evidence is used to show that force or coercion was used. b. Evidence is used to identify the assailant. c. Evidence is used to determine the assailant's reason to rape. d. Evidence is used to confirm recent sexual contact. e. Evidence is used to corroborate the survivor's story.

Evidence is used to confirm recent sexual contact. Evidence is used to show that force or coercion was used. Evidence is used to identify the assailant. Evidence is used to corroborate the survivor's story. Rationale: An important legal concept when dealing with rape survivors is the need to preserve the chain of evidence, meaning that all physical evidence and specimens must remain in the hands of a professional until they are turned over to a police officer. The evidence that the nurse or forensic examiner collects has four primary uses (Ledray, 1999): 1) to confirm recent sexual contact; 2) to show that force or coercion was used; 3) to identify the assailant; and 4) to corroborate the survivor's story.

The nurse is counseling a prenatal client regarding the need to take folic acid supplements during pregnancy. The nurse also encourages the client to eat foods high in folic acid, such as: a. Eggs and yogurt. b. Fresh green, leafy vegetables and legumes. c. Rice and pasta. d. Fruits and fruit juice.

Fresh green, leafy vegetables and legumes. Rationale: Fresh green, leafy vegetables and legumes are good sources of folic acid. Fruits and fruit juice, rice and pasta, eggs, and yogurt are not sources of folic acid.

A client is being maintained at home with a diagnosis of mild pre-eclampsia. Which of the following complaints require further evaluation? Select all that apply. a. Headache. b. Anxiety. c. Heartburn. d. Blurred vision.

Headache. Blurred vision. Rationale: Answers (c) and (d) are correct; headache and blurred vision are symptoms associated with worsening preeclampsia. Answer (a) is incorrect; heartburn is a familiar sensation and is less intense than the epigastric pain associated with severe preeclampsia. Answer (b) is incorrect; anxiety is a normal response to a complicated pregnancy.

A client at 15 weeks' gestation presents to the prenatal clinic with "prune juice"-like vaginal bleeding. Other assessment data include a hematocrit of 10 and complaints of severe nausea and vomiting. What diagnosis should the nurse suspect? a. Prolapsed cord. b. Hydatidiform mole. c. Placenta previa. d. Abruptio placentae.

Hydatidiform mole. Rationale: In hydatidiform mole, vaginal bleeding occurs almost universally. It is often brownish due to liquefaction of the uterine clot. In addition, because serum hCG levels are higher with molar pregnancy than with normal pregnancy, the woman might experience hyperemesis gravidarum. Anemia occurs frequently due to blood loss and poor nutrition secondary to hyperemesis. Placenta previa symptoms include painless bright red vaginal bleeding, usually in the third trimester of pregnancy. Prolapsed cord symptoms include a trickle of bright red vaginal blood and possibly a visible cord at the vaginal opening. Abruptio placentae symptoms include vaginal bleeding (bright red or dark red), abdominal pain, and uterine tenderness.

The nurse is reviewing the lab tests of four prenatal clients. Which lab finding would support the diagnosis of hyperemesis gravidarum? a. Hypercalcemia. b. Hypokalemia. c. Hyperkalemia. d. Hypocalcemia.

Hypokalemia. Rationale: In severe cases, hyperemesis causes dehydration, which leads to fluid-electrolyte imbalance. Severe potassium loss can disrupt cardiac functioning. Potassium loss (hypokalemia), not hyperkalemia, is characteristic of hyperemesis gravidarum. Neither hypercalcemia nor hypocalcemia (low calcium) is characteristic of hyperemesis gravidarum.

If a client does not respond to standard home treatment for severe hyperemesis gravidarum, the nurse will anticipate adding which therapy on an outpatient basis? a. Low-fat soft diet. b. Complex carbohydrates with limited liquids. c. IV fluids. d. Total parenteral nutrition.

IV fluids. Rationale: If the woman does not respond to standard approaches to the control of nausea and vomiting in pregnancy, she might require intravenous (IV) fluids on an outpatient basis. Total parenteral nutrition would be started only if the client were unresponsive to IV hydration. Low-fat soft diet and complex carbohydrates with limited liquids are progressive diets after the client is stabilized for hyperemesis gravidarum.

The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)? a. Ingestion of the drug accelerates intoxication. b. White sediment develops in the drink laced with Rohypnol. c. After ingestion, the client may become hyperactive. d. Always smell your drinks, because adding the drug to a drink creates a citrus aroma.

Ingestion of the drug accelerates intoxication. Rationale: Flunitrazepam (Rohypnol), a potent sedative-hypnotic that is legal in 80 countries worldwide but illegal in the United States, received considerable attention as the "date rape drug of choice" in the late 1990s. Typically Rohypnol, which dissolves easily and is odorless, is slipped into the drink of an unsuspecting woman. Because these drugs frequently produce amnesia, the woman may be unable to remember details of her assault, thereby making prosecution more difficult.

The nurse is teaching a client with diabetes about insulin requirements during pregnancy. Which statement should the nurse include regarding insulin requirements? a. Insulin needs decrease late in the third trimester. b. Insulin needs decrease early in the third trimester. c. Insulin needs increase early in the first trimester. d. Insulin needs increase in the second trimester.

Insulin needs increase in the second trimester. Rationale: During the first trimester, the need for insulin frequently decreases. Insulin requirements begin to rise in the second trimester as glucose use and glucose storage by the woman and fetus increase. Insulin requirements can double or quadruple by the end of pregnancy as a result of placental maturation and hPL production.

A client with Type I diabetes is admitted to the labor and birthing unit. What nursing actions should take priority in the intrapartal management of the patient with diabetes? Select all that apply. a. Hourly monitoring of coagulation studies. b. Hourly monitoring of blood sugar level. c. Maintaining two patent IV lines. d. Maintaining seizure precautions.

Maintaining two patent IV lines. Hourly monitoring of blood sugar level. Rationale: Frequently, maternal insulin requirements decrease dramatically during labor. Consequently, maternal glucose levels are measured hourly to determine insulin need. Often two IV lines are used, one with a 5% dextrose solution and one with a saline solution. The saline solution is then available for piggybacking insulin, or if a bolus is needed. Seizure precautions and coagulation are not priorities in diabetes.

The nurse working on the sexual assault response team (SART) responds to a rape victim report in the emergency room. What will this nurse collect first when gathering medical and forensic data? a. Scrape under the victim's fingernails. b. Photograph any physical injuries. c. Mark clothing and seal in an airtight bag. d. Obtain a detailed history of the event.

Obtain a detailed history of the event. Rationale: The first step in obtaining sufficient evidence following a rape is to obtain a detailed history of the event, followed by a careful physical examination, including the collection of specimens.

The nurse is caring for a laboring client with sickle-cell anemia. Which therapy should the nurse anticipate the physician ordering? a. Diuretics. b. Magnesium sulfate. c. Oxygen. d. Bronchodilators.

Oxygen. Rationale: Oxygen supplementation is an anticipated therapy for patients with sickle-cell anemia, to reduce the risk of their red blood cells sickling in the presence of decreased oxygen. Diuretics, magnesium sulfate, and bronchodilators are not anticipated for patients with sickle-cell anemia.

The client asks for information about ectopic pregnancy. The nurse correctly responds by saying ectopic pregnancy is caused by: (Select all that apply.) a. Pelvic inflammatory disease (PID). b. Presence of an IUD. c. In utero exposure to diethylstilbestrol (DES). d. Endometriosis.

Pelvic inflammatory disease (PID). Endometriosis. Presence of an IUD. In utero exposure to diethylstilbestrol (DES). Rationale: Ectopic pregnancy can be caused by tubal damage from pelvic inflammatory disease (PID), previous tubal surgery, congenital anomalies of the tube, endometriosis, previous ectopic pregnancy, presence of an IUD, and in utero exposure to diethylstilbestrol (DES).

The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her next assessment questions should explore which type of abuse? a. Sexual abuse. b. Sociological abuse. c. Physical abuse. d. Psychologic abuse.

Psychologic abuse. Rationale: Domestic violence is defined as a pattern of coercive behaviors and methods used to gain and maintain power and control by one individual over another in an adult intimate relationship. Forms of abuse vary, but are typically described as falling into the following categories, which the batterer uses to maintain control over his partner's behavior and the relationship: psychologic abuse, physical abuse, sexual abuse, and threats of physical or sexual violence.

A client who has admitted to heavy alcohol use throughout her pregnancy just delivered a 6-pound baby. Which signs and symptoms in the mother should the nurse anticipate in the 12-48-hour postpartum period? Select all that apply. a. Neonatal abstinence syndrome. b. Fetal alcohol syndrome. c. Seizures. d, Delirium tremens.

Seizures. Delirium tremens. Rationale: As a result of alcohol dependence, the woman might have withdrawal seizures as early as 12-48 hours after she stops drinking. Delirium tremens could occur in the postpartum period, and the newborn might suffer a withdrawal syndrome. Neonatal abstinence and fetal alcohol syndrome are not maternal symptoms.

The nurse is providing prenatal care to an asymptomatic HIV-infected client. Which nursing interventions should take priority? Select all that apply. a. Taking the client's temperature. b. Performing a vision test. c. Performing a hearing test. d. Skin assessment.

Taking the client's temperature. Performing a vision test. Skin assessment. Rationale: In monitoring the asymptomatic pregnant woman who is HIV-positive, the nurse needs to be alert for nonspecific symptoms such as fever, weight loss, fatigue, persistent candidiasis, diarrhea, cough, skin lesions, and behavior changes. These can be signs of developing symptomatic HIV infection. At each prenatal visit, asymptomatic, HIV-infected women are monitored for early signs of complications, such as weight loss in the second or third trimesters, or fever. The clinician inspects the mouth for signs of infections such as thrush (candidiasis) or hairy leukoplakia; the lungs are auscultated for signs of pneumonia; and the lymph nodes, liver, and spleen are palpated for signs of enlargement. Each trimester the woman should have a visual examination and examination of the retina to detect such complications as toxoplasmosis. Performing a hearing test is not a priority intervention.

The social worker has informed the community health nurse that a couple with a history of domestic violence is currently in the tension-building phase of the cycle of violence. Which situation is most likely to be assessed by the nurse during the home care visit? a. The woman states that leaving is not the solution. She has a sprained wrist. b. The male partner sent flowers and candy. He is loving and sorrowful of his actions. c. The home is disorderly. There is a large bruise under the woman's right eye, and her lip is swollen. d. The woman is hopeful that her acceptance of blame will diminish the violence.

The woman is hopeful that her acceptance of blame will diminish the violence. Rationale: In the tension-building phase, the batterer demonstrates power and control. This phase is characterized by anger, arguing, blaming the woman for external problems, and possibly minor battering incidents. The acute battering incident is typically triggered by some external event or internal state of the batterer. It is an episode of acute violence distinguished by lack of predictability and major destructiveness. The tranquil phase is also sometimes called the honeymoon period. This phase may be characterized by extremely loving, kind, and contrite behaviors by the batterer as he tries to make up with the woman, or it may simply be manifested by an absence of tension and violence.

A prenatal client at 16 weeks' gestation presents to the clinic with unexplained bright red bleeding, cramping, and backache, which she has had for the past two days. A pelvic exam reveals a closed cervix. What type of abortion does this indicate? a. Threatened. b. Incomplete. c. Missed. d. Imminent.

Threatened. Rationale: A threatened abortion (miscarriage) has symptoms of vaginal bleeding and backache without cervical dilation. In an imminent abortion, the internal cervical os is dilated. Although the cervix is closed in a missed abortion, other symptoms would include a regression in breast changes and a brownish vaginal discharge. Diagnosis is made based on history, pelvic exam, and a negative pregnancy test. With an incomplete abortion, the embryo has passed out of the uterus, but the placenta remains, and the internal os is slightly dilated.