Maternal and Child Health Nursing Practice Quiz (3,1,2,4,5,

The mother asks the nurse. "What's wrong with my son's breasts? Why are they so enlarged?" Which of the following would be the best response by the nurse?

"A decrease in material hormones present before birth causes enlargement"

The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

"Alcohol helps it dry and kills germs"

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

"Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.

When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breastfeeding success?

"I support your commitment; however, you may have to supplement each feeding with formula."

When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her?

"If I have blurred or double vision, I should call the clinic immediately."

The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:

"Nausea and vomiting can be decreased if I eat a few crackers before arising"

A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond?

"No, it can initiate premature uterine contractions."

Which of the following would be the nurse's most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa?

"The placenta is covering the opening of the uterus and blocking your baby."

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test?

"This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting, the nurse might ask which question?

"What changes have you made at home to get ready for the baby?"

Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first?

"What is your expected due date?

A postpartum primipara asks the nurse, "When can we have sexual intercourse again?" Which of the following would be the nurse's best response?

"When the discharge has stopped and the incision is healed.

A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count (DFMC). Which instructions could be included in the plan of care? Select all that apply.

-The patient can monitor fetal activity once daily for a 60-minute period and note activity. -Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted. -Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.

After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at (-1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is:

1 cm above the ischial spines.

When assessing the newborn's heart rate, which of the following ranges would be considered normal if the newborn were sleeping?

100 beats per minute

FHR can be auscultated with a fetoscope as early as which of the following?

20 weeks gestation

Which of the following represents the average amount of weight gained during pregnancy?

24 to 30 lb

A adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:

3 full days of elevated basal body temperature and clear, thin cervical mucus

A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs?

3 ounces

What is the approximate time that the blastocyst spends traveling to the uterus for implantation?

7 days

The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

A bright red discharge 5 days after delivery

Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy?

A total gain of 25 to 30 pounds

With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?

Above the maternal umbilicus and to the left of midline

A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding?

Abruptio placentae

Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?

Abruptio placentae

Which of the following is the most common kind of placental adherence seen in pregnant women?

Accreta

A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

Activity limited to bed rest

Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?

Ambivalence, fear, fantasies

Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Apply gentle pressure to the site with a sterile gauze pad

A client LMP began July 5. Her EDD should be which of the following?

April 12

A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense:

Around the pelvic girdle

Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following shouldthe nurse do first?

Assist her to urinate

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

At 30 weeks of gestation

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time?

At the beginning of each fetal movement

When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?

Bartholin's gland

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time?

Between 16 and 20 weeks' gestation

Which of the following best reflects the frequency of reported postpartum "blues"?

Between 50% and 80% of all new mothers report some form of postpartum blues

Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?

Blink, cough, sneeze, ga

A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices:

Blurred vision

Which of the following is the primary predisposing factor related to mastitis?

Breast injury caused by overdistention, stasis, and cracking of the nipples

The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

Breast-feeding the neonate at frequent intervals

Normal lochial findings in the first 24 hours post-delivery include:

Bright red blood

A multigravida at 38 weeks' gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?

Cervical dilation

During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following?

Chadwick's sign

The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

Change the client's position.

When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?

Check the vital signs every 2 to 4 hours

On which of the following areas would the nurse expect to observe chloasma?

Cheeks, forehead, and nose

The nurse understands that the fetal head is in which of the following positions with a face presentation?

Completely extended

Which of the following would the nurse assess in a client experiencing abruptio placenta?

Concealed or external dark red bleeding

When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections?

Condoms

Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?

Cools incubator wall

Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?

Decreased gastric acidity

The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first?

Determine the amount of lochia

When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided?

Diaphragm

When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority?

Dietary intake

The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis?

Doppler blood flow analysis

When preparing to listen to the fetal heart rate at 12 weeks' gestation, the nurse would use which of the following?

Doppler placed midline at the suprapubic region

Which of the following would the nurse identify as a classic sign of PIH?

Edema of the hands and face

Which behaviors would be exhibited during the letting-go phase of maternal role adaptation. Select all that apply.

Emergence of family unit Sexual intimacy relationship continuing Defining one's individual roles

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant.

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

Endometritis

A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions?

Every 15 minutes

Immediately before expulsion, which of the following cardinal movements occur?

External rotation

During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?

Facilitate relaxation, possibly reducing the perception of pain

Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

Facilitating safe and effective self-and newborn care

Immediately after a delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding?

Fetal body flexion or extension

During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?

First trimester

A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient?

Fluid volume deficit

Before birth, which of the following structures connects the right and left auricles of the heart?

Foramen ovale

A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?

Fractured clavicle

Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?

Frequency

When measuring a client's fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

From the symphysis pubis to the fundus

When taking an obstetrical history on a pregnant client who states, "I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,"the nurse should record her obstetrical history as which of the following?

G4 T1 P1 A1 L2

In the past, factors to determine whether a woman was likely to have a high-risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category?

Geographic

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?

Gonorrhea

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

Hand/face edema

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?

Have the client breathe into her cupped hands.

During the first 4 hours after a male circumcision, assessing for which of the following is the priority?

Hemorrhage

A client tells the nurse, "I think my baby likes to hear me talk to him." When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response?

High-pitched speech with tonal variations

A client 12 weeks' pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation.The nurse would document these findings as which of the following?

Imminent abortion

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

Impaired bowel motility related to pain medication and immobility

A client in her third trimester tells the nurse, "I'm constipated all the time!" Which of the following should the nurse recommend?

Increased fiber intake

Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?

Increasing intensity with walking

With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that:

Infants with asymmetric IUGR have the potential for normal growth and development.

Which of the following best describes thrombophlebitis?

Inflammation of the vascular endothelium with clot formation on the vessel wall

The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, "The baby is coming!" which of the following would be the nurse's first action?

Inspect the perineum

Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?

Instructing the client to use two or more peri pads to cushion the area

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST):

Is considered to have a negative result if no late decelerations are observed with the contractions.

A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth?

Ischial spines

Which of the following best describes preterm labor?

Labor that begins after 20 weeks gestation and before 37 weeks gestation

Which change would the nurse identify as a progressive physiological change in postpartum period?

Lactation

Which of the following danger signs should be reported promptly during the antepartum period?

Leaking amniotic fluid

When uterine rupture occurs, which of the following would be the priority?

Limiting hypovolemic shock

A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

Lochia

After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:

Lubricate her nipples with expressed milk before feeding

A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first?

Maintain a patent airway

For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following?

Maintain hormonal levels

What is an appropriate indicator for performing a contraction stress test?

Maternal diabetes mellitus and postmaturity

Which of the following factors is the underlying cause of dystocia?

Mechanical

The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following

Meconium

In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests?

Missed

When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?

Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth

Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?

More than 500 ml

Which of the following factors would the nurse suspect as predisposing a client to placenta previa?

Multiple gestation

Which of the following assessment findings would the nurse expect if the client develops DVT?

Muscle pain the presence of Homans sign, and swelling in the affected limb

After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

Nausea and Vomiting

Which of the following would the nurse identify as a presumptive sign of pregnancy?

Nausea and vomiting

Which of the following are the most commonly assessed findings in cystitis?

Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain

A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus:

Nonstress testing is performed weekly until 32 weeks' gestation.

While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action?

Notify the physician immediately

A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure? Select all that apply.

Observe the patient for possible uterine contractions. Administer RhoGAM to the patient if she is Rh negative.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first?

Obtain a serum glucose level

After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

Obtaining an order to begin IV oxytocin infusion

The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele's rule, the nurse determines her EDD to be which of the following?

October 21

Because cervical effacement and dilation are not progressing in a patient in labor,the doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration?

Oxytocin causes water intoxication

When PROM occurs, which of the following provides evidence of the nurse's understanding of the client's immediate needs?

PROM removes the fetus most effective defense against infection

Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

Pain

The nurse documents positive ballottement in the client's prenatal record. The nurse understands that this indicates which of the following?

Passive movement of the unengaged fetus

A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

Perineum

A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which of the following persons must the nurse notify?

Physician who will attend the delivery of the infant

Which of the following is the nurse's initial action when umbilical cord prolapse occurs?

Place the client in a knee-chest position in bed

Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?

Placing crib close to nursery window for family viewing

Which of the following actions demonstrates the nurse's understanding about the newborn's thermoregulatory ability?

Placing the newborn under a radiant warmer

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

Pregnancy should be avoided for 3 months after the immunization

In the late 1950s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept?

Prepared childbirth

A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time?

Preparing for immediate delivery

When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?

Pressure on blood vessels from the enlarging uterus

When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to:

Prevent seizures

While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client's fundus to:

Prevent uterine inversion

Cervical softening and uterine souffle are classified as which of the following?

Probable signs

A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?

Prolapsed umbilical cord

When teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases?

Proliferative phase

For which of the following clients would the nurse expect that an intrauterine device would not be recommended?

Promiscuous young adult

Which of the following nursing interventions would the nurse perform during the third stage of labor?

Promote parent-newborn interaction.

While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?

Protamine sulfate

A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?

Proteinuria, headaches, double vision

Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do?

Recognize this as normal first period of reactivity

A pregnant client states that she "waddles" when she walks. The nurse's explanation is based on which of the following as the cause?

Relaxation of the pelvic joints

The post term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following?

Respiratory problems

Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta?

Rigid, board-like abdomen

The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?

Risk for deficient fluid volume related to hemorrhage

Which of the following prenatal laboratory test values would the nurse consider as significant?

Rubella titer less than 1:8

During which of the following stages of labor would the nurse assess "crowning"?

Second stage

To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following?

Secretion of estrogen by the fetal gonad

A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client's plan of care?

Seizure precautions

A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, "We know several friends in our age group and all of them have their own child already, Why can't we have one?". Which of the following would be the most pertinent nursing diagnosis for this couple?

Self-esteem disturbance related to infertility.

Which of the following statements best describes hyperemesis gravidarum?

Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems

After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective?

Shortens the second stage of labor

When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?

Sperm motility

When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?

Startle reflex

A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:

Tailor sitting

A client at 8 weeks' gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question?

Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water

Forty eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?

Taking hold

Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

Tell her to breastfeed more frequently

When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells?

Testosterone

Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?

Tetanic contractions prolonged to more than 90 seconds

Which of the following is true regarding the fontanels of the newborn?

The anterior is large in size when compared to the posterior fontanel.

Which of the following would be inappropriate to assess in a mother who's breastfeeding?

The baby's lips smacking

Which of the following would be disadvantage of breast feeding?

The father may resent the infant's demands on the mother's body

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

The fetus isn't in distress at this time.

For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

The membranes must rupture

Which of the following describes the Babinski reflex?

The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.

The nurse in-charge is reviewing a patient's prenatal history. Which finding indicates a genetic risk factor?

The patient has a child with cystic fibrosis

Which of the following would cause a false-positive result on a pregnancy test?

The test was performed less than 10 days after an abortion

A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?

The ultrasound identifies blood flow through the umbilical cord

Barbiturates are usually not given for pain relief during active labor for which of the following reasons?

They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.

A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?

Transitional phase

The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?

Transitional phase

A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time?

Transvaginal ultrasound

A female adult patient is taking a progestin-only oral contraceptive, or mini pill. Progestin use may increase the patient's risk for:

Tubal or ectopic pregnancy

When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation?

Two ova fertilized by separate sperm

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?

Two weeks before menstruation

During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies?

Ultrasound

Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?

Uric acid crystals

Which of the following fundal heights indicates less than 12 weeks' gestation when the date of the LMP is unknown?

Uterus in the pelvis

While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically:

Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn.

When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?

Vastus lateralis muscle

While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?

Yogurt

Which of the following refers to the single cell that reproduces itself after conception?

Zygote

A client makes a routine visit to the prenatal clinic. Although she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:

grapelike clusters.