Maternity A
The nurse provides education on increasing dietary iron to a client diagnosed with anemia. The nurse recommends the client eat which food? A. Chicken livers. B. Pork chop. C. Hamburger. D. Bananas. E. Spinach. F. Tofu.
A. Chicken livers. E. Spinach. F. Tofu. Explanation: Liver is an excellent concentrated source of iron with 7.2 mg of iron per serving. The recommended daily dietary iron intake for females ages 19-50 is 18 mg/day, men ages 19 and up and postmenopausal women is 8 mg/day. Other concentrated sources include cooked artichokes and fortified cereals. Green leafy veggies and legumes are excellent sources of dietary iron. Tofu can be a good source of concentrated iron, especially for the client who may not eat meat. B. Pork is not a concentrated source of iron, however pork liver is an excellent source of concentrated iron, 15.2 mg per 3 oz serving. C. Hamburger is not a concentrated source of iron. Beef liver does not contain as much iron as pork or chicken liver. Red meat in the form of steaks contains more iron per serving than hamburger. Organ meats are excellent sources of iron. D. Bananas are not a good source of iron.
A client is prescribed a colposcopy. The nurse tells the client which information about the purpose of this procedure? A. Magnifies the tissue for examination. B. Directly examines ovaries, fallopian tubes, uterus, and small intestine. C. Views structures in the pelvic cavity. D. Visualized the bladder.
A. Magnifies the tissue for examination. Explanation: A colposcopy is an examination of the vagina and cervix using a colposcope. This test identifies precancerous lesions of the cervix by magnifying the tissue for examination. The nurse should instruct a client that some bleeding may occur after the procedure. The client can use vaginal tampons, however the client should report heavy bleeding. B. A colposcopy is performed laparoscopy and performed under general anesthesia. C. This describes culdoscopy. After the procedure, position the client on the abdomen with pillow underneath to expel air that entered the abdominal cavity. The nurse should assess vital signs and observe for vaginal bleeding. D. This describes a cystoscopy. Post-procedure, the nurse should report bleeding to the healthcare provider.
The nurse provides care for a client immediately after a normal vaginal deliver. Which action does the nurse take FIRST? A. Observes the lochial flow. B. Palpates the fundus. C. Obtains a warming blanket. D. Obtains vital signs.
A. Observes the lochial flow. Explanation: Observing the lochial flow allows the nurse to directly check for hemorrhage. Inspection is the first step of the physical assessment. Other actions may be necessary after this observation is made. B. It is important to assess for a firm fundus, but more important to observe for hemorrhage. If the nurse assesses heavy bleeding, massaging the fundus would be appropriate. C. This is an appropriate action but not the priority for the client. Many clients experience intense tremor-like chills following delivery. The nurse should provide a warm blanket. D. The nurse should check vital signs every 15 minutes during the first hour following delivery. It is most important for the nurse to observe hemorrhage.
A client is in active labor when the membranes rupture. The client tells the nurse, "I am afraid of having a 'dry labor'." Which response by the nurse is BEST? A. "Amniotic fluid does not function as lubrication for the labor process." B. "The sac actually impedes the progress of labor and if not ruptured, the healthcare provider would've had to do it artificially." C. "Labor is only slightly more difficult with early rupture of the amniotic sac." D. "Now that there is limited amniotic fluid, you may have to have a cesarean birth."
A. "Amniotic fluid does not function as lubrication for the labor process." Explanation: Amniotic fluid helps maintain constant body temperature, provides oral fluids, and cushions the fetus. It does not provide lubrication for birth. Secretions from the Bartholin glands-two pea sized lands at the entrance to the vagina-help keep the vagina lubricated. B. The artificial rupture of membranes may augment labor, however answer A better addresses the client's concern. C. This is not a true statement. Rupture of membranes has no bearing on the difficulty of labor. D. This is not a true statement. The amount of amniotic fluid is not indicative of a cesarean section or vaginal birth. A cesarean birth at this stage of labor would only occur with fetal and/or maternal distress
The nurse prepares a client diagnosed with uterine cancer for a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The nurse observes that the client is talking continuously and has difficulty maintaining eye contact. Which response by the nurse is BEST? A. "What are your concerns about the surgery." B. "Why isn't your husband here with you?" C. "Are you afraid that you are going to die." D. "You seem to be coping with the surgery very well."
A. "What are your concerns about the surgery." Explanation: The client's behavior indicates anxiety. Both the diagnosis and the extensive surgery are anxiety provoking. The nurse should allow the client to verbalize feelings. Abdominal hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, fallopian tubes, and ovaries. B. This response is judgmental and may increase the client's anxiety. C. This question is nontherapeutic and does not encourage the client to express feelings. D. The client's behavior suggests anxiety. Signs of anxiety include restlessness, pacing, glancing about, poor eye contact, repeating things over and over, foot shuffling, and fidgeting.
A primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains which changes in insulin requirements will occur in pregnancy? A. Insulin requirements will increase during pregnancy and decrease after delivery. B. Insulin requirements will decrease during pregnancy and increase after delivery. C. Insulin requirements will increase during pregnancy and remain increased after delivery. D. Insulin requirements decrease during pregnancy and remain decreased after delivery.
A. Insulin requirements will increase during pregnancy and decrease after delivery. Explanation: Due to hormonal interference in glucose metabolism, insulin requirements increase during pregnancy. The need for more insulin is caused by hormones the placenta makes to help the baby grow. At the same time, these hormones block the action of the mother's insulin. Immediately after delivery, the insulin requirements usually decrease abruptly. B. Insulin requirements increase during pregnancy and decrease after the birth of the baby. C. After delivery, the client regains the pre pregnancy sensitivity to insulin and insulin requirements decrease. D. During the months of pregnancy, the need for insulin will go up. This is especially true during the last three months of pregnancy. Following delivery, the need for insulin will decrease.
The nurse ambulates a postpartum client to the bathroom for the first time after the client gave birth three hours ago. The client reports feeling a sudden gush of bleeding from the vagina while ambulating. Which is the MOST likely cause of the bleeding? A. Lochia has pooled in the client's vagina. B. A cervical tear needs to be repaired. C. The fundus is relaxed and requires massaging. D. The client may have bladder distention and needs to void.
A. Lochia has pooled in the client's vagina. Explanation: The flow of lochia increases during ambulation due to the pooling in the vagina while the client is lying or sitting. Lochia flow can also increase during breastfeeding. Lochia contains blood, mucus, and uterine tissue and typically continues for four to six weeks after childbirth. B. A cervical tear would result in excessive. bright red bleeding. C. A relaxed fundus can cause bleeding, but bleeding would continue to occur, not just when the client stands or ambulates. D. A distended bladder causes the fundus to rise above the umbilicus and does not cause a gush of fluid to occur.
The nurse assesses four newborns. Which characteristic noted by the nurse are most common in a preterm infant? A. Red, wrinkled skin, lanugo, and hypotonic muscles. B. Vernix caseosa, silky hair, and facial edema. C. Absent nose bridge, depressed fontanels, and absent lanugo. D. Mottles skin, meconium stools, and hypertonic muscles.
A. Red, wrinkled skin, lanugo, and hypotonic muscles. Explanation: Red, wrinkled skin is due to the lack of subcutaneous fat, which accumulates during the third trimester. Lanugo is downy fine hair found on shoulders, forehead, and cheeks and is more noticeable in preterm infants. Floopy, poor head control and limp extremities indicate hypotonia, also more prevalent in the preterm infant. B. These characteristics describe a full-term infant. Vernix is a white cheesy substance that acts as protective covering for the infant's skin. C. Depressed fontanels indicate fluid volume deficit. A low or absent nasal bridge can indicate a genetic disorder. Neither finding is characteristic of a preterm infant. D. Meconium stool is normal. Mottled skin is a symptom of cold stress, and hypertonia is not seen with preterm infants.
A client arrives at the hospital in labor. The client is 4 cm dilated and 60% effaced. Which statement does the nurse give the client to explain the meaning of this information? A. The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal. B. The cervix is 4 cm short in dilatation and 60% thinner than normal. C. The walls of the cervix are 4 cm thick and 60% shorter than normal. D. The cervix is 4 cm long and 60% wider than normal.
A. The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal. Explanation: Dilatation is stretching of the cervical os from an opening a few mm in size to an opening large enough to allow the passage of the infant (0-10 cm). Effacement is the thinning and shortening or obliteration of the cervix. This occurs in late pregnancy and/or labor. B. Dilatation is measured in 0-10 cm. Effacement is the thinning and shortening or obliteration of the cervix. C. Effacement is the thinning and shortening of the cervix. D. Dilatation is stretching of the external cervical os from an opening a few mm in size to an opening large enough to allow the passage of the infant (0-10 cm). Effacement is the thinning and shortening of the cervix.
A client reports experiencing weight gain and muscle cramps during the menstrual period. The nurse suggests which measures to the client to alleviate these symptoms? A. Use a mild analgesic, restrict caffeine, exercise moderately. B. Avoid analgesics, rest frequently, drink herbal tea. C. Restrict fluid intake, exercise moderately, increase caffeine. D. Restrict sodium intake, avoid exercise, use sedatives.
A. Use a mild analgesic, restrict caffeine, exercise moderately. Explanation: The use of mild analgesics, such as over the counter NSAIDS, restriction of caffeine, and moderate exercise have all been shown to be effective in relief of the weight gain, irritability, and muscle cramping of a menstrual period. B. NSAIDSs are very effective for muscle cramps. Rest is important but moderate exercise relieves menstrual discomfort by increased vasodilation. Herbal teas may be caffeinated. The client should restrict caffeine. C. The client should maintain hydration and decrease caffeine intake. D. Decreasing sodium will decrease fluid retention, but moderate exercise and NSAIDs are recommended to relieve symptoms.
A client comes to the prenatal clinic for the first visit. The nursing history reveals the client's last menstrual period was five months ago, and the client is certain of pregnancy, and reports feeling the baby move. Which response by the nurse is BEST? A. "Since you have felt fetal movement, I am sure that you are pregnant." B. "Lie down so that I can listen for fetal heart tones with the Doppler." C. "We'll collect a urine specimen for testing to confirm that you are pregnant." D. "Have you noticed feeling more fatigued lately?"
B. "Lie down so that I can listen for fetal heart tones with the Doppler." Explanation: Auscultating fetal heart tones, visualization of the fetus by ultrasound or x-ray, or fetal movement palpated by the examiner are all positive signs of pregnancy. A. Amenorrhea and fetal movement reported by the client are presumptive signs of pregnancy. Other presumptive signs include breast changes, nausea and vomiting, urinary frequency, and fatigue. The client would need further testing to conclude pregnancy. C. The urine pregnancy test could be conducted as early as the first day of a missed period, serum blood levels may also be drawn. Auscultation of fetal heart tones is the least invasive method of determining pregnancy at this stage. D. Fatigue is a presumptive signs of pregnancy, however a person can experience fatigue for various reasons.
An infant shows a tendency to bleed two days after birth. The nurse understands that it is MOST likely caused by which reason? A. Hemophilia. B. Absence of intestinal bacteria and Vitamin K. C. An immature liver that is unable to synthesize clotting factors. D. Delayed production of red blood cells.
B. Absence of intestinal bacteria and Vitamin K. Explanation: At birth, infants have very little Vitamin K stored in the body because only small amounts pass through the placentas from their mothers. The bacteria that produce Vitamin K are not yet present in a newborn's intestines. The newborns are given Vitamin K at birth. Vitamin K is produced in the GI tract after microorganisms are introduced. Infants are able to produce some Vitamin K by day 8, but typically can not produce sufficient Vitamin K until they begin taking solid foods around age 4 to 6 months. Infants who do not receive the Vitamin K shot at birth can develop Vitamin K deficiency bleeding (VKDB) at any time up to 6 months of age. A. Hemophilia is a hereditary blood disease that causes prolonged coagulation time. Bleeding tendencies in the newborn are due to the baby's inability to produce Vitamin K. C. Immature hepatic function causes the neonate to be unable to deal with bilirubin production due to the breakdown of RBCs after birth. This can lead to physiologic jaundice, not bleeding. D. This may cause physiologic anemia, but does not increase the bleeding in the newborn. Newborn babies do not start to produce new red blood cells until about 1 month of age. This causes a mild type of anemia called physiologic or normal anemia. Once a baby starts making new red blood cells, the red blood cell count gradually goes back to normal.
The nurse identifies which pregnant woman as MOST likely to have a problem with Rh incompatibility with the fetus? A. An Rh-positive client who conceived with a Rh-negative partner and has two children who are Rh-positive. B. An Rh-negative client who conceived with a Rh-positive partner and gave birth 3 years ago to an Rh-positive infant. C. An Rh-positive client who conceived with a Rh-positive partner, who previously aborted a fetus at 12 weeks gestation. D. An Rh-negative client who conceived with a Rh-negative partner and never received Rh0 (D) immune globulin.
B. An Rh-negative client who conceived with a Rh-positive partner and gave birth 3 years ago to an Rh-positive infant. Explanation: Since Rh-positive is dominant, as long as there is one positive partner, the infant will be Rh-positive. In this case, the infant will be Rh-positive and mother Rh-negative. If the mother is Rh-negative, the immune system treats Rh-positive fetal cells as if they were a foreign substance. The mother's body makes antibodies against the fetal blood cells. Firstborn infants are often not affected unless the mother had past miscarriages or abortions. This is because it takes time for the mother to develop antibodies. Due to the previous pregnancy, Rh antibodies that the mother has formed will break down infant's blood cells. The nurse would need to determine if the client received Rho (D) immune globulin after the previous pregnancy. A. Rh incompatibilities occur when the mother is Rh-negative and the fetus is Rh-positive. C. Because both parents are Rh-positive, and the child is Rh-positive, there will be no incompatibility. D. The infant will be Rh-negative. Rho (D) immune globulin is given when the mother is Rh-negative and there is a chance the mother is carrying an Rh-positive infant. It is given at 28 weeks gestation or immediately after birth.
A client is in active labor. As labor progresses, the client becomes irritable and reports feeling increasingly uncomfortable. The client is 8 cm dilated. Which action does the nurse take FIRST? A. Contacts the health care provider. B. Coaches the client in proper breathing and relaxation techniques. C. Administers an analgesic. D. Removes the fetal monitor to allow the client to move around.
B. Coaches the client in proper breathing and relaxation techniques. Explanation: Assist the client to cope with the transition phase of labor. Stay with the client, provide constant reassurance, help the client to reestablish breathing patterns, and provide comfort. If available, assist the partner in the coaching to feel included in the laboring process. A. The client is in the transition phase of labor, which causes a definite increase in intensity of symptoms. This is expected and the HCP does not need to be notified at this time. C. Narcotic analgesics are contraindicated during the transition phase of labor. They can cause respiratory depression of the newborn. D. Although this is an appropriate intervention, it is more important to help with breathing and relaxation at this time.
The nurse monitors a client at 30 weeks gestation, and the client reports periodic heartburn. It is MOST important for the nurse to make which recommendation? A. Lie down after eating a meal. B. Eat frequent small meals. C. Take Alka-Seltzer as needed. D. Sip milk in between meals.
B. Eat frequent small meals. Explanation: The client should avoid large meals and gas producing, spicy, fatty, or fried foods. This will decrease the symptoms of GERD. A. It is best to remain sitting up after eating. The increased progesterone produced during pregnancy slows GI tract motility and relaxes the cardiac sphincter allowing the reflux of gastric contents into the esophagus. C. Is is best to avoid sodium bicarbonate, which might interfere with sodium balance as well as aspirin. The client may take aids such as Tums, Rolaids, or Maalox for occasional GERD symptoms. D. While its true that milk can temporarily buffer stomach acid, when the fat from the milk is digested it increases the acid in the stomach. Therefore it is best not to drink milk when experiencing an exacerbation of GERD.
A client had a cesarean delivery. The nurse placed the HIGHEST priority on monitoring the client for which potential complication? A. Infection and pain. B. Hemorrhage and shock. C. Hemorrhage and pain management. D. Dehydration and infection.
B. Hemorrhage and shock. Explanation: The client is not only on an obstetrical client but also a postoperative client; observe for patent airway, and observe incisional dressing for bleeding and amount of lochia. A. Pain is a priority during the postpartum period, but assessing for hemorrhage and shock is a higher priority. Infection is usually detected 48-72 hours after a cesarean delivery. C. During the first few days, incisional pain and pain form intestinal gas is a problem; pain medication given q 3-4 hours. It is important to change positions, splint incision, and teach relaxation techniques. Assessing for shock is a higher priority. D. Dehydration and infection are important to monitor, but hemorrhage and shock is the highest priority for this client.
When the nurse accidentally bumps into a newborn's bassinet, the newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which reflex? A. Tonic neck. B. Moro. C. Babinski. D. Rooting.
B. Moro. Explanation: The Moro reflex is also called the startle reflex, and occurs in response to a loud noise or sudden movement. It disappears at 3 to 4 months. A. Tonic neck reflex is the fencing position. The infant lies on the back with the head turned to one side. The arm and leg on that side of the body will be in extension while extremities on opposite side will be flexed. This involuntary reflex disappears at 3 to 4 months. C. Stroking the sole of the foot from heel upward across the ball of the the foot will cause all toes to fan. This reflex reverts to the usual adult response by 12 months. In the adult response the great toe and other toes will flex and the foot will pull back from the stimulus. D. The infant turns toward any object when the cheek or mouth is stroked on that side.
The nurse prepares a client for an abdominal hysterectomy. The client asks why an indwelling catheter is required. Which statement by the nurse is MOST appropriate? A. "This will help you since you will be temporary incontinent." B. "This will enable us to measure your output accurately." C. "This will promote healing by decompressing your bladder." D. "This will allow your bladder to recover after the surgery."
C. "This will promote healing by decompressing your bladder." Explanation: An overextended bladder may interfere with wound healing by pressing on the wound. The indwelling catheter is usually removed when the client begins ambulating. A. The client will not be incontinent due to the surgery. B. An indwelling urinary catheter does enable staff to measure output accurately, but it is more important to decompress the bladder immediately after surgery. D. The bladder is not affected by the surgery. The nurse will monitor urinary output after the catheter is removes to ensure the client can void without difficulty.
The nurse assesses an infant born by vaginal delivery. At birth, the infant is crying and moving all extremities, and respirations and pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. Which is the Apgar score for the baby at one minute and five minutes? A. 8 and 9, respectively. B. 7 and 10, respectively. C. 9 and 10, respectively. D. 7 and 9, respectively.
C. 9 and 10, respectively. Explanation: The baby is crying with normal muscle tone, and heart rate. At one minute the baby's extremities are cyanotic indicating an overall score of 9. At 5 minutes the extremities are pink, indicating an overall score of 10. The Apgar assessment is used to quickly relay the status of a newborn's overall condition and determine if there is a need for resuscitation. Five categories of assessment are used. Activity or muscle tone is assessed with scores ranging from 0 points if baby is limp or floppy, 1 point if limbs flexed, to 2 if there is active movement. Pulse is assessed from 0 points for absent heart rate, 1 point for less than 100 beats per minute, to 2 points for greater than 100 beats per minute. Grimace, or response to stimulation, is assessed from 0 points for absent response, 1 point for facial movement with stimulation, to 2 points for cough or sneeze, cry, withdrawal of foot with stimulation. Appearance is assessed at 0 points if the baby is blue, bluish-gray, or pale all over, 1 point if the body is pink but extremities are blue, to 2 points for pink all over. Respiration/breathing is assessed at 0 points if respirations are absent, 1 point for irregular and weak crying, and 2 points if the baby has a good, strong cry. A. All areas of the assessment are at the highest level at one minute except for the baby's color. The one minute score is 9. At 5 minutes all areas are assessed at the highest level, or a score of 10. Apgar scores of 0-3 indicates severe distress, 4-6 indicates moderate distress, 7-10 indicates good adjustment to extrauterine life. B. The baby assesses at an Apgar score of 9 at 1 minute. D. The baby scores well in all categories except for a slight decrease in score at 1 minute due to cyanosis of the extremities.
The nurse understands which medication is most likely prescribed for a client with a diagnosis of gonorrhea? A. Penicillin vaginal suppositories. B. Penicillin G benzathine intramuscularly in divided doses once a week. C. Ceftriaxone IM plus doxycycline for seven days by mouth. D. Ampicillin by mouth.
C. Ceftriaxone IM plus doxycycline for seven days by mouth. Explanation: The CDC recommends a one time dose of ceftriazone IM and a 7 day course of oral doxycycline as the primary treatment for gonorrhea. The nurse should instruct about preventing the transmission of sexually transmitted infections. A. Penicillin vaginal suppositories are not used to treat gonorrhea. B. A single IM injection of penicillin G is the treatment of choice for syphilis. D. Oral ampicillin is not a treatment for gonorrhea.
When administering phototherapy to a newborn with jaundice, it is MOST important for the nurse to take which action? A. Expose the infant's back to the light. B. Remove the infant from the light for 15 minutes each hour. C. Cover the infant's eyes with protective pads during therapy. D. Check the infant's temperature every hour.
C. Cover the infant's eyes with protective pads during therapy. Explanation: The nurse should cover the infant's eyes to protect them from the fluorescent lights. The nurse should ensure the nares are not covered with a mask and should close the infant's eyes prior to placing the mask over the eyes. Eye pads or an eye mask should be removed during feeding so the eyes can be checked and the parents can have visual contact with the infant. A. The nurse should turn the infant every 2 hours to expose all of the body to the light. B. The infant should be left under the light as much as possible. The nurse should feed the infant every 3-4 hours and group activities such as changing and feeding in order to minimize interruptions in the therapy. D. The infant's temperature may become elevated due to the light or decreased due to being uncovered. The nurse should monitor the infant's temperature at least every 4 hours.
The nurse assesses an apical pulse on a 8 lb 4 oz (3742.14 g) newborn infant. The nurse takes which action? A. Places the diaphragm of the stethoscope between the left nipple and the sternal notch. B. Places the diaphragm of the stethoscope between the second and third intercostal spaces at the left midaxillary line. C. Places the bell of the stethoscope at the fourth intercostal space at the left midclavicular line. D. Places the bell of the stethoscope between the second and third intercostal spaces at the left sternal border.
C. Places the bell of the stethoscope at the fourth intercostal space at the left midclavicular line. Explanation: The correct location for assessment of the apical pulse in infants is at the 4th intercostal space, left midclavicular line. S1, normal closing of the mitral and tricupsid valves, is best heard at this location. The bell transmits low-pitched sounds like heart and vascular sounds and may help detect the presence of a murmur. A. The apical pulse is located at the 4th intercostal space at the left midclavicular line in infants and children up to age 4 or 5. The bell or diaphragm of the stethoscope can be used, but the bell transmits soft, low-pitched sounds, such as heart murmurs. B. The nurse should place the stethoscope at the fourth intercostal space at the left midclavicular line. D. This placement is used to assess the pulmonary area. S2, normal closing of the aortic and pulmonic valves, is best heard at this location.
The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's blood pressure is 150/96, serum albumin level is 3 g/dL (30 g/L), 3 + protein is found in the urine, and the client's face and hands are edematous. Which instruction by the nurse is MOST important? A. The client should decrease caloric intake. B. The client should eliminate all salt from the diet. C. The client should ensure adequate protein. D. The client should increase the intake of iron.
C. The client should ensure adequate protein. Explanation: The client has preeclampsia. The client will be placed on bedrest lying on the left side and will be instructed to maintain adequate intake of fluids and protein. Proteins restore osmotic pressure. A. The client should not diet. The client should maintain adequate intake of foods and fluids. B. Salt restriction is not required because pregnant women with hypertension typically have lower plasma volume. The edema is due to decreased colloidal osmotic pressure from protein loss, not excess sodium in the diet. If the client has chronic hypertension controlled by a low-salt diet prior to pregnancy, decreased salt in the diet would be recommended. C. Altering iron in the diet does not affect preeclampsia.
A pregnant client comes to the clinic. The client questions the nurse about the amount of exercise that is acceptable during the pregnancy. Which is the MOST important response by the nurse? A. "You can continue your activities but rest when you get tired." B. "You should take a brisk walk daily." C. "You can exercise as much as you want but limit household activities." D. "What is your usual type of exercise?"
D. "What is your usual type of exercise?" Explanation: The client should exercise at least three times per week. It is most important to determine regular exercise regimen before recommending an exercise program to the client. A. Exercise improves muscle tone and potentially shortens the client's labor. This is correct information to give to the client, but it is important to assess previous exercise prior to implementing a new exercise plan. Remember the nursing process: assessment, diagnosis, planning, implementation, and evaluation. B. The nurse needs to assess what kind of exercise in which the client normally participates. The prenatal exercise routine should be within the client's level of tolerance. C. The client should exercise three times per week. There is no reason to limit household activities at this point. It is important for the client to drink plenty of fluids during exercise.
A client in active labor suddenly shouts, "I have to push! I have to push!" The nurse determines the client is 8 cm dilated. Which action does the nurse take FIRST? A. Instructs the client to take a deep breath and bear down. B. Applies pressure to the client's fundus. C. Coaches the client in relaxation techniques. D. Encourages the client to pant with pursed lips.
D. Encourages the client to pant with pursed lips. Explanation: The nurse should encourage the client to pant to prevent pushing. The nurse should instruct the client to avoid holding the breath by breathing in and out constantly or by raising the chin and blowing or panting. A. The client is not completely dilated and should not push until fully 10 cm dilated. Pushing before full dilation can result in swelling of the cervix and increased difficulty with delivery. B. The nurse should stay with the client and encourage the client to reestablish breathing patterns. Pushing on the client's fundus is not an appropriate action at this time. C. The nurse can use relaxation techniques during labor, but it is more important to reestablish breathing to prevent pushing for the client with the strong urge to push.
The nurse prepares a client for a gynecological examination. The nurse explains that a pelvic examination will be preformed and a Pap smear obtained. The nurse gives the client which information about the Pap smear? A. It is taken from exudates of the vagina and cervix. B. It is a sample of tissue used to locate a lesion. C. It is an x-ray film taken from various angles. D. It is a scraping of the cervix used to identify abnormal cells.
D. It is a scraping of the cervix used to identify abnormal cells. Explanation: A Pap smear is a routine procedure to identify infectious processes, the presence of abnormal cells, and hormonal changes. It is obtained by scraping cells from the cervix and sending the specimen to the laboratory. A. The cells are scraped from the cervix. The client is instructed to not douche, use vaginal medication, or have sexual intercourse for at least 24 hours prior to procedure. The nurse should reschedule if the client is menstruating. B. A Pap smear is used to determine cervical cancer. C. A Pap smear is collected from the cervix.
The nurse provides care for a client after a breast biopsy. Immediately after the procedure, it is MOST important for the nurse to take which action? A. Apply ice to the area. B. Reposition the client for comfort. C. Carefully transport the specimen to the lab. D. Observe for bleeding.
D. Observe for bleeding. Explanation: In the initial post-biopsy period, ligation of an artery or vein is the greatest risk. The nurse will observe for frank bleeding and pallor, cold and clammy skin, and increased pulse and decreased blood pressure. The nurse will always assess before implementing. A. The nurse will avoid cold to prevent nipple contractions that may stress the incision. B. For female clients, a supportive bra should be worn continuously for one week. The client may take a mild analgesic for pain or use a heating pad. This is an important action but not the priority after the procedure. C. First, the nurse will take care of the client.
The nurse instructs a client who recently had a modified radial mastectomy. The nurse explains it is very important for the client to exercise the affected arm. Which statement by the nurse is the MOST important reason for the client to exercise the arm? A. Increases muscle strength and diameter. B. Maintains body balance. C. Limits full range of motion. D. Prevents lymphedema.
D. Prevents lymphedema. Explanation: Postoperatively, the nurse will encourage the client to perform prescribed exercises and elevate the extremity on the affected side to prevent lymphedema. Exercising the arm muscles pumps lymph fluid back into circulation. The client should position the arm on a pillow with each joint higher than the proximal joint elevation. A. The primary purpose for exercising the affected arm after a mastectomy is to prevent lymphedema. Lymphedema is the pooling of lymph circulation in the involved arm after removal of lymph glands. B. The nurse should advise the client not to sleep on the affected arm and should encourage use of arm in activities of daily living. C. Early use of the affected hand and arm will prevent atrophy and contractures and will enhance fluid return. The client should be encouraged to perform full range of motion, not limit the range of motion.
The nurse instructs a client how to prevent conception using the basal body temperature (BBT) method. The nurse explains that during ovulation, the basal body temperature will change in which direction? A. Lowers significantly B. Rises significantly C. Is unchanged D. Rises slightly
D. Rises slightly Explanation: Just prior to ovulation, the basal body temperature lowers 1 degrees, however at the time of ovulation, the body temperature increases about 1-2 degrees. This slight rise is important for clients who rely on methods of childbirth planning that depend upon knowledge of the ovulatory cycle. A. Temperature lowers prior to ovulation; however, at the time of ovulation, it rises. B. Temperature rises slightly after ovulation. To avoid conception, avoid unprotected intercourse from the day the basal body temperature drops and for 3 days after the temperature elevates. C. Temperature should decrease 2-4 days prior to menstruation. If temperature remains elevates, pregnancy has occurred.
The nurse provides care for a client in labor. The fetus is displaying occasional category 3 fetal heart rate patterns on the monitor. What is the FIRST action for the nurse to perform? A. Immediately call the health care provider. B. Time the contractions from the beginning of one contraction to the beginning of the next contraction. C. Have the client roll onto her right side and take deep breaths. D. When the fetal heart rate is baseline perform fetal stimulation to assess for heart rate acceleration.
D. When the fetal heart rate is baseline perform fetal stimulation to assess for heart rate acceleration. Explanation: Fetal stimulation is another method of fetal assessment to use in conjunction of electronic fetal monitoring to provide additional information about the fetal status when category 3 fetal heart patterns are observed. Fetal stimulation is performed to elicit an acceleration of the fetal heart rate of 15 bpm for at least 15 seconds and/or improve fetal heart rate variability. There are two methods: scalp stimulation (digital pressure applied to the fetus' scalp during vaginal exam) and vibroacoustic stimulation (the use of an artificial device positioned over the fetal head for 1 to 2 seconds). Both procedures can be performed with or without ruptured membranes. They should ONLY be performed when the fetal heart rate is baseline. Acceleration of the fetal heart rate is usually indicative of fetal well-being, and absence of acceleration is usually indicative of a need to conduct further fetal evaluation. A. Although category 3 fetal heart rate patterns are a cause for concern, the nurse should further assess the client and fetus before calling the health care provider. B. This is appropriate when measuring the time between contractions, although not appropriate to further assess the fetus. C. This is incorrect. If the fetus is sustaining late decelerations, the appropriate action is to roll the client to the left side and apply oxygen. When placing the client on her side, it decreases the pressure on the inferior vena cava, increasing oxygenation to the fetus.
