Maternity Final Practice Questions

Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? A. Pica B. Caffeine intake C. Alcohol abuse D. Artificial sweetener use

A (Pica) (Reasoning: The practice of pica, especially the ingestion of heavy metals, must be considered when pregnant women are found to be anemic. Caffeine, alcohol, and artificial sweeteners are not directly linked to anemia in pregnant women.)

The nurse is caring for four postpartum clients, each with a different medical condition. Which condition will result in the primary health care provider advising the new mother not to breast-feed? A. Mastitis B. Inverted nipples C. Herpes genitalis D. Human immunodeficiency virus (HIV) infection

D (HIV) (Explanation: Breast-feeding by a mother infected with HIV is contraindicated, because breast milk can transmit the virus to the infant. A mother with mastitis would be counseled to continue breast-feeding during treatment for mastitis. Breast-feeding is not contraindicated in a client with inverted nipples. If the infant cannot latch, a breast shield can provide mild suction to help evert the nipples. Breast-feeding is not contraindicated in a client with genital herpes. The newborn may contract the infection during a vaginal birth but not from breast milk.)

What kind of decelerations during a CST or during labor are associated with uteroplacental insufficiency?

Late

How much additional daily protein intake is required by the lactating client?

25 g

The first day of a client's last menstrual period was July 22. Which is the estimated date of birth (EDB)?

April 29th (Reasoning: EDB = last menstrual period + 1 year - 3 months + 7 days.)

When assessing a client who gave birth 1 day ago, the nurse finds the fundus is firm at 1 fingerbreadth below the umbilicus and the perineal pad is saturated with lochia rubra. Which is the nurse's next action?

Asking the client when she last changed the perineal pad

Which client statement leads the nurse to conclude that the client has been experiencing menorrhagia? A. "It hurts when I have intercourse." "I have a foul-smelling vaginal discharge." "I have bleeding between my menstrual periods." "I have severe bleeding during my menstrual periods."

D ("I have severe bleeding during my menstrual periods.") (Explanation: Menorrhagia is severe bleeding during a menstrual period. Painful intercourse is the definition of dyspareunia. Foul-smelling vaginal discharge is a sign of a vaginal infection. Metrorrhagia is uterine bleeding that occurs at any time other than during the menstrual period._

Where would the fundal height be located in a pregnant client at 16 weeks' gestation?

Halfway to the umbilicus

_____________ is the final stage of lochia; rather than blood, you will see a __________________ discharge that is generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around ________ after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than 2 weeks.

Lochia alba; white or yellowish; 6 weeks

Information about which factor can be obtained by means of an amniocentesis done during the 16th week of gestation?

Neural tube defect (Reasoning: Alpha-fetoprotein in amniotic fluid is increased in the presence of a neural tube defect. Lung maturity cannot be determined until after 35 weeks' gestation. Neither diabetes nor cardiac disorders can be detected with the use of amniocentesis.)

The nurse is assessing a newborn with exstrophy of the bladder. Which other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?

Pubic bone malformation

Which term would the nurse use to describe the first fetal movements that a pregnant client feels?

Quickening

Which description explains striae gravidarum encountered in a client in her 26th week of gestation?

Reddish streaks on the abdomen and breasts (Explanation: Reddish streaks on the abdomen and breasts are striae gravidarum; they occur as a result of stretching of the breast and abdominal skin. These are known as "stretch marks.")

Offspring of men of advanced paternal age are at an increased risk for which condition?

Schizophrenia

The transition phase of labor is the _________ of the first stage of labor.

last stage

A client at the fertility clinic is being treated for hypertension and obesity and has lost 8 lb (3.6 kg) in the past month, and her blood pressure has decreased to 154/98 mmHg. She states she is using self-control strategies to achieve these improvements. Which would be a therapeutic response by the nurse?

Acknowledging the client's achievement while encouraging continuation of her current program

Which is a sensory simulation strategy a laboring client can use as a nonpharmacological strategy for pain management? A. Gentle massage of the abdomen B. Biofeedback-assisted relaxation techniques C. Application of a heat pack to the lower back D. Selecting a focal point and beginning breathing techniques

D (Selecting a focal point and beginning breathing techniques) (Reasoning: Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.)

Which statement is an accurate description of dysmenorrhea?

Pain with menses

A primigravida in the first trimester tells the nurse that she has heard that hormones play an important role in pregnancy. Which hormone would the nurse tell the client maintains pregnancy?

Progesterone (Explanation: Produced by the ovaries and placenta, progesterone is a female sex hormone that prepares the endometrium for implantation of the fertilized ovum, maintains pregnancy, and plays a role in the development of the mammary glands.)

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration?

Slow, weak cry

Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation?

Straw colored, clear, and containing little white specks (Reasoning: By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.)

A pregnant client asks how smoking will affect her baby. Which information about cigarette smoking will influence the nurse's response?

The resulting vasoconstriction affects both fetal and maternal blood vessels. (Reasoning: Cigarette smoking or continued exposure to secondary smoke causes both maternal and fetal vasoconstriction, resulting in fetal growth retardation and increased fetal and infant mortality.)

The nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse identify?

Tonic neck (Explanation: The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month.)

After her baby's birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time?

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

How many milligrams of calcium would the nurse instruct the 30-year-old client to consume during pregnancy?

1000 mg

Which time during the menstrual cycle would the nurse stress as the optimal time to achieve pregnancy?

14 days before the next period

The school nurse would teach the students that the ovum is no longer viable at which time interval after ovulation?

24 hours (Explanation: The ovum is viable for about 24 hours after ovulation; if not fertilized before this time, it degenerates)

The nurse is teaching a family planning class about ovulation and conception. For which period of time would the nurse inform the class that the ovum is capable of being fertilized after ovulation?

24 to 36 hours

A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare? A. A high-forceps birth B. An immediate cesarean birth C. Insertion of an internal fetal monitor D. Administration of an oxytocin infusion

B (An immediate cesarean birth)

A client who recently was told by her primary health care provider that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. Which stage of death and dying is the client experiencing?

Denial

Which information would the nurse provide to the breast-feeding client asking how human milk compares with cow's milk?

Fat in human milk is easier to digest and absorb than the fat in cow's milk.

Which information about nausea and vomiting in the first trimester would the nurse provide to the pregnant client?

It may be related to an increased human chorionic gonadotropin level. (Can also be unknown)

The third stage of labor begins after ______, continues until the separation of the placenta from the uterine wall, and ends with the ______________________.

birth; expulsion of the placenta

What is the Goodell sign?

softening of the cervix

What is the Hegar sign?

softening of the lower uterine segment

Which statement would be the basis for the nurse's response when a laboring client expresses concern about the effect that an intravenous (IV) analgesic may have on her fetus?

"The medication will be administered during a contraction, when the uterine blood vessels are constricted." (Reasoning: Giving the medication during a contraction, when the uterine vessels are constricted, keeps the medication within the maternal vascular system for several seconds and decreases the effect on the fetus)

The nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant?

Between 45% and 65% (Explanation: Less than 40% is below the expected level and is considered anemia. More than 75% is high and is considered polycythemia. Between 65% and 75% is above the expected range.)

The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy?

Breaks down the bilirubin into a conjugated form (Explanation: Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces.)

For which complication would a client who has had a spontaneous abortion be assessed? A. Hemorrhage B. Dehydration C. Hypertension D. Subinvolution

A (Hemorrhage) (Reasoning: Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth.)

Which information would the nurse include in the discharge teaching of a postpartum client? A. The prenatal Kegel tightening exercises should be continued. B. A bowel movement may not occur for up to a week after the birth. C. The episiotomy sutures will be removed at the first postpartum visit. D. A postpartum checkup should be scheduled as soon as menses returns.

A (The prenatal Kegel tightening exercises should be continued.) (Reasoning: Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.)

A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How would the nurse respond? A."Your lower rib cage is more restricted." B. "Your diaphragm has been displaced upward." C. "Your lungs have increased in size since you got pregnant." D. "The height of your rib cage has increased since you got pregnant."

B ("Your diaphragm has been displaced upward.") (Reasoning: The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration. The lower rib cage expands; it does not become restricted. There is no change in the size of the lungs during pregnancy. The thoracic cage enlarges; it does not rise.)

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." Which action would the nurse take to confirm that the membranes have ruptured? A. Take the client's oral temperature. B. Test the leaking fluid with nitrazine paper. C. Obtain a clean-catch urine specimen. D. Inspect the perineum for leaking fluid.

B (Test the leaking fluid with nitrazine paper.) (Reasoning: Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the initial assessment. Although this may be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic fluid. Inspecting the perineum for leaking fluid will not confirm rupture of the membranes.)

Which statement accurately describes the current advice regarding breast self-examination (BSE)?

BSE should be taught to all women. It is true that the American Cancer Society and breastcancer.org continue to recommend self-examinations. BSEs do not clearly decrease mortality. Rather than save women from unnecessary testing, they tend to result in unnecessary procedures, including biopsies. It's best to do self-examinations when breasts are not tender or swollen as they often are right before or after menstruation.

Which client statement indicates understanding of teaching about a nonstress test? A. "I'll need to have an intravenous (IV) line so the medication can be injected before the test." B. "My baby may get very restless after I have this test." C. "I hope this test doesn't cause my labor to start too early." D. "If the heart reacts well, my baby should do OK when I give birth."

D ("If the heart reacts well, my baby should do OK when I give birth.") (Reasoning: The nonstress test is used to evaluate the response of the fetus to movement and activity. A reactive test indicates that the fetus is healthy. No injections of any kind are used during a nonstress test; it involves only the use of a fetal monitor to record the fetal heart rate during periods of activity. The nonstress test will not influence the activity of the fetus because no exogenous stimulus is used. Early labor is unlikely because the nonstress test is noninvasive.)

Which sexually transmitted infection is caused by protozoa?

Trichomoniasis

Which nutritional deficiency in pregnant women places the infant at risk for malformations of the central nervous system?

Zinc (Reasoning: Zinc deficiency in pregnant women is associated with malformations of the central nervous system in infants. Malformations of the central nervous system in infants are not associated with sodium, potassium, or magnesium deficiencies in pregnant women.)

The onset of strong contractions occurs during the active phase of the _______ stage of labor.

first

A prenatal client's vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client's clinical record? A. Hegar B. Goodell C. Chadwick D. Braxton-Hicks

C (Chadwick's sign) (Reasoning: A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton-Hicks contractions, can be felt through the abdominal wall.)

Which problem is suggested when a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity followed by fundal tenderness and a small amount of dark-red bleeding? A. True labor B. Placenta previa C. Partial abruptio placentae D. Abdominal muscular injury

C (Partial abruptio placentae) (Reasoning: Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.)

When the fetal monitor is applied to a client's abdomen, it records late decelerations. Which action would the nurse take? A. Notify the health care provider. B. Elevate the head of the bed. C. Reposition the client on her left side. D. Administer oxygen by way of facemask.

C (Reposition the client on her left side) (Reasoning: Late decelerations may indicate impaired placental perfusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the health care provider is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.)

Which medication is safe to take during pregnancy? Select all that apply. One, some, or all responses may be correct. A. Metronidazole B. Aspirin C. Codeine D. Acetaminophen E. Diphenhydramine HCl

D (Acetaminophen) (Explanation: Acetaminophen may be taken safely during all stages of pregnancy. Metronidazole should not be used during the first trimester of pregnancy. Salicylates like aspirin, codeine, and antihistamines like diphenhydramine HCl should be avoided throughout pregnancy.)

Which complication is prevented by coaching a client in the second stage of labor to take a breath at least every 6 seconds while pushing with each contraction? A. Fetal hypoxia B. Perineal lacerations C. Carpopedal spasms D. Maternal hypertension

A (Fetal hypoxia) (Reasoning: Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.)

Which symptom indicates pelvic inflammatory disease? Select all that apply. One, some, or all responses may be correct. A. Fever B. Elevated erythrocyte sedimentation rate (ESR) C. Chronic pelvic pain D. Irregular vaginal bleeding E. Abnormal vaginal discharge F. Bilateral adnexal tenderness

All are correct

Which cause may produce abnormal uterine bleeding? Select all that apply. One, some, or all responses may be correct. A. Hypothyroidism B. Failure to ovulate C. Bleeding disorders D. Unidentified pregnancy E. Use of oral contraceptives F. Benign lesions of the uterus

All are correct (Explanation: Common causes for any type of abnormal uterine bleeding include endocrine disorders like hypothyroidism; failure to ovulate or respond appropriately to ovulation hormones; bleeding disorders; pregnancy complications such as an unidentified pregnancy that is ending in spontaneous abortion; breakthrough bleeding, which may occur in the woman taking oral contraceptives; and lesions of the vagina, cervix, or uterus (benign or malignant).)

Which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beats over the baseline rate of 135 beats per minute that lasts 15 seconds?

An acceleration (Reasoning: An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate.)

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?

G5 T1 P1 A2 L2 (Reasoning: The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had 1 term (T) pregnancy (1 that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions.)

Which definition would the nurse use to explain osteoporosis?

It involves a decrease in bone substance.

For which reason is a postpartum client encouraged to walk?

Peripheral vasomotor activity is promoted

The second stage of labor begins with _______________ and ends with the ________________________.

full cervical dilation; birth of the infant

How would the nurse respond to a primigravida who says, "It's so fast. Is that normal?" when first hearing the fetal heartbeat of 150 beats/minute (bpm)?

"Normal range for fetal heart rate at 12 weeks' gestation is 120 to 180 bpm."

A client is being initiated on bisphosphonates. Which advice will the nurse provide?

"Take it on an empty stomach."

A client has just given birth to an infant with Down syndrome. The mother is crying and asks the nurse what she is supposed to do now. Which response would the nurse give?

"Tell me what you know about Down Syndrome."

A 16-year-old high school student comes to a community health center because of the fear of having contracted herpes. The teenager is upset and shares this information with the community health center nurse. Which response would the nurse provide?

"You sound worried. Let me make arrangements to have you examined."

A fetoscope cannot pick up the fetal heartbeat until which week?

17th

Which is the priority nursing intervention for the postpartum client whose fundus is 3 fingerbreadths above the umbilicus, boggy, and midline? A. Massaging the uterine fundus B. Helping the client to the bathroom C. Assessing the peri-pad for the amount of lochia D. Administering intramuscular methylergonovine (Methergine) 0.2 mg

A (massaging the uterine fundus) (Reasoning: A uterus that is displaced and above the umbilicus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine (Methergine) is administered.)

When calculating the Apgar score for a newborn, which would the nurse assess in addition to the heart rate? A. Muscle tone B. Amount of mucus C. Degree of head lag D. Depth of respirations

A. Muscle tone (Explanation: The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not the depth, is assessed for an Apgar score. Amount of mucus, degree of head lag, and depth of respirations are not tested for an Apgar score.)

Which assessment finding would the nurse question for a client who is considering oral contraceptives? Select all that apply. One, some, or all responses may be correct. A. Blood clots B. Heart disease C. Breast cancer D. Impaired liver function E. Undiagnosed vaginal bleeding F. Smoking more than 15 cigarettes per day

All are correct

Which action would the nurse include in the plan of care for a client who is being treated for a sexually transmitted infection and reports fever and irregular bleeding? Select all that apply. One, some, or all responses may be correct. A. The use of analgesics B. Abdominal palpation C. Complete blood count D. Culture of the cervical canal E. Administration of antibiotics as prescribed F. Teaching about negative effects of douching

All are correct (Explanation: Sexually transmitted infection is a common cause of pelvic inflammatory disease (PID). Symptoms include fever, chronic pelvic pain, abnormal vaginal discharge, nausea and anorexia, and irregular vaginal bleeding. Analgesics may be needed to provide for patient comfort. Palpation of the abdomen and pelvic organs may reveal tenderness. A complete blood count may reveal elevated leukocytes and sedimentation rate. Cultures of the cervical canal are done to identify the infecting organism, which most commonly is Neisseria gonorrhoeae or Chlamydia trachomatis. Urinalysis is usually done to identify infection of the urinary tract. Antimicrobials are begun promptly to treat the infection. Douching results in changes in the vaginal flora and predisposes the woman to the development of PID, bacterial vaginosis, and ectopic pregnancy.)

Which disease is in the top five leading causes of death in American women?

Alzheimer (Explanation: Alzheimer disease is the fifth leading cause of death among American women. Diabetes mellitus is the seventh, unintentional injury is the sixth, and influenza and pneumonia are the eighth.)

When are the developing cells of a pregnancy considered an embryo?

At the end of the 2nd week of pregnancy

Which would the nurse include in a teaching plan for a new mother and her infant? A. A schedule for teaching infant care B. A demonstration and explanation of infant care C. A discussion of mothering skills presented in a nonthreatening manner D. Emotional support that will foster dependence on the nurse's expertise

B (A demonstration and explanation of infant care) (Explanation: Teaching the mother by example is a nonthreatening approach that allows her to proceed at her own pace. Learning does not occur on a schedule; questions must be answered as they arise. New mothers need demonstration of appropriate mothering skills, not just a discussion. Although emotional support is required, the plan should encourage independent caregiving.)

Which postpartum complication would the nurse monitor for in a client with hydramnios? A. Infection B. Hemorrhage C. Hypertension D. Thromboembolism

B (Hemorrhage) (Reasoning: A client with hydramnios is at risk for hemorrhage in the postpartum period. Infection, hypertension, and thromboembolism are not specific risk factors related to hydramnios.)

A neonate born at 39 weeks' gestation is small for gestational age. Which commonly occurring problem would the nurse anticipate when planning care for this infant? A. Anemia B. Hypoglycemia C. Protein deficiency D. Calcium deficiency

B (Hypoglycemia) (Explanation: Hypoglycemia is common in newborns who are small for gestational age because of malnutrition in utero; the nurse can detect this with a blood glucose test and notify the primary health care provider. Polycythemia, not anemia, is more likely to occur. Although a protein deficiency may occur, it is not life threatening at this time. Although hypocalcemia may occur, it is not as common as hypoglycemia.)

Which guideline regarding sexual intercourse would be given to a client with preterm contractions and cervical dilation of 2 cm? A. It should be limited to once a week. B. It is prohibited because it may stimulate labor. C. It should be restricted to the side-lying position. D. It is permitted as long as penile penetration is shallow

B (It is prohibited because it may stimulate labor.) (Reasoning: Prostaglandins in semen may stimulate labor, and penile contact with the cervix may increase myometrial contractility. Sexual intercourse may cause labor to progress; it is contraindicated for the rest of the pregnancy. The position is irrelevant, because sexual intercourse is contraindicated for the rest of the pregnancy. Regardless of the extent of penile penetration, sexual intercourse may precipitate labor; it is contraindicated for the rest of the pregnancy.)

Which statement made by a pregnant client after a prenatal class on fetal growth and development indicates the need for additional teaching? A. "The baby is smaller if the mother smokes." B. "The baby gets food from the amniotic fluid." C. "The baby's oxygen is provided by the mother." D. "The baby's umbilical cord has 2 arteries and 1 vein."

B (The baby gets food from the amniotic fluid) (Reasoning: The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, to supply blood containing nutrients and oxygen.)

A pregnant client with a history of heart disease asks how she can relieve her occasional heartburn. Which statement indicates that the client understands the teaching the nurse has provided? A. "I should lie down for an hour after I eat." B. "I shouldn't drink more than 32 ounces of fluid a day." C. "I won't take antacids that contain sodium." D. "I plan to eat 3 large meals throughout the day."

C ("I won't take antacids that contain sodium.") (Reasoning: Antacids containing sodium may increase fluid retention, which increases the workload of the heart and is therefore not recommended. Lying down for 1 hour after eating will exacerbate heartburn because it promotes gastric regurgitation. Fluid intake should be approximately 2 quarts (64 ounces, 2000 mL) a day and does not directly address the heartburn, which is the client's question. Three large meals a day will distend the stomach, which could result in heartburn. Small frequent meals, spaced throughout the day, are preferred.)

The nurse teaches a client who is about to undergo an amniocentesis that ultrasonography will be performed just before the procedure to determine which? A. Gestational age of the fetus B. Amount of fluid in the amniotic sac C. Position of the fetus and the placenta D. Location of the umbilical cord and placenta

C (Position of the fetus and the placenta) (Reasoning: The position of the fetus and placenta is located by means of ultrasonography to assist in preventing trauma from the needle during the amniocentesis. Although ultrasonography can be used to determine gestational age, this is not its purpose before an amniocentesis. Determining the amount of fluid in the amniotic sac is not the purpose of ultrasonography just before an amniocentesis. The position of the placenta and fetus, not just the cord and the placenta, is needed for safe introduction of the needle.)

During the first hour after a cesarean birth, the nurse notes that the client's lochia has saturated one perineal pad. Which clinical judgment would the nurse make based on this finding? A. Scant lochial flow B. Postpartum hemorrhage C. Retained placental fragments D. Lochial flow within expected limits

D (Lochial flow within expected limits) (Reasoning: It is expected that as many as two perineal pads will be saturated in the first hour. Hemorrhage would saturate more than two pads in 1 hour. Retained placental fragments would be accompanied by heavy bleeding and require more than two pads during the first hour.)

Early in the ninth month of pregnancy a client experiences painless vaginal bleeding secondary to a placenta previa. Which intervention would the client's plan of care include? A. Giving vitamin K to promote clotting B. Performing a rectal examination to assess cervical dilation C. Administering an enema to prevent contamination during birth D. Placing the client in the semi-Fowler position to increase cervical pressure

D (Placing the client in the semi-Fowler position to increase cervical pressure) (Reasoning: Placing the client in the semi-Fowler position forces the heavy uterus to put pressure on the blood vessels at the site of the separating placenta, controlling bleeding to some extent. There is no indication that the clotting mechanism is disturbed. Performing a rectal examination is contraindicated with placenta previa; it may further dislodge the placenta. Enemas are contraindicated in any client admitted with vaginal bleeding.)

When can a primigravida fetal heartbeat be heard for the first time?

Doppler ultrasound at 10 to 12 weeks

At which point during a human pregnancy does the embryo become a fetus?

During the 8th week of the pregnancy (Reasoning: During the 8th week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the 2nd week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.)

Which is a gastrointestinal manifestation of infection in the newborn? Select all that apply. One, some, or all responses may be correct. A. Lethargy B. Irritability C. Nasal flaring D. Poor perfusion E. Glucose instability

E (Glucose instability) (Explanation: Glucose instability is a gastrointestinal manifestation of newborn infection. Lethargy and irritability are central nervous systems changes associated with infection. Nasal flaring is a respiratory manifestation of infection. Poor perfusion is a cardiovascular manifestation of infection.)

Which finding is indicative of hypothermia in a newborn? Select all that apply. One, some, or all responses may be correct. A. Seizures B. Diaphoresis C. Flushed skin D. Poor feeding E. Hypoglycemia

E (Hypoglycemia) (Explanation: Hypoglycemia in a newborn can indicate hypothermia or cold stress. Seizures, diaphoresis, flushed skin, and poor feeding are indicative of hyperthermia.)

What kind of decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor?

Early

While conducting prenatal teaching, the nurse explains to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. Which factor does the nurse identify as the cause of this increase?

Increased production of estrogen

According to Naegele rule, which is the expected date of delivery (EDD) of a client whose last menstrual period began on April 15?

January 22nd (Reasoning: To determine EDD with the use of Naegele rule, subtract 3 months from the date of the last menstrual period and add 7 days)

Which intervention would the nurse recommend to relieve symptoms of a yeast infection?

Using a sitz bath

What kind of decelerations are associated with cord compression during a CST or during labor?

Variable

Which is an appropriate response to a client who is 8 weeks pregnant and is concerned because she doesn't "feel like making love to her husband since becoming pregnant" and she doesn't "think he understands"?

"A decrease in libido is common during the first trimester of pregnancy."

The nurse is teaching participants in a prenatal class regarding breast-feeding versus formula feeding. A client asks, "What is the primary advantage of breast-feeding?" Which response is most appropriate?

"Breast-fed infants have fewer infections." (Reasoning: Maternal antibodies are transferred from the mother in breast milk, providing protection for a longer time than do antibodies transferred to the fetus by way of the placenta. The neonate is protected by the antibodies and thus has fewer infections. The fetus' own antibody system is immature at birth.)

The nurse identifies a right cephalohematoma on an otherwise healthy 1-day-old newborn. Which would the nurse teach the parents at the time of discharge? A. To space feedings at every 3 hours B. How to assess the fontanels for tenseness C. How to monitor their child for signs of jaundice D. To record the number of wet diapers during the first 24 hours

C (How to monitor their child for signs of jaundice) (Explanation: Bilirubin is a yellow pigment derived from the hemoglobin released with the breakdown of red blood cells as the hematoma resolves. Signs of jaundice should be reported.)

Two days after delivery a client has a temperature of 101°F (38.3°C), general malaise, anorexia, and chills. Which clinical finding would the nurse expect to identify on the client's laboratory report? A. Increased hemoglobin level B. Decreased C-reactive protein C. Increased white blood cell (WBC) count D. Right-shift differential WBC count

C (Increased white blood cell (WBC) count) (Reasoning: An increased WBC count is indicative of an infectious process. In postpartum clients hemoglobin values usually decrease because of the typical blood loss during the birth process. C-reactive protein is increased during an infectious process. A right-shift differential WBC count occurs in clients with liver disease and pernicious anemia; a shift to the left occurs in an infectious process and is related to an increase in immature neutrophils.)

Which immediate action would the nurse take if a client in the active phase of labor says, "I feel all wet. I think I wet myself."? A. Give her the bedpan. B. Change the bed linens. C. Inspect her perineum. D. Take an oral temperature

C (Inspect her perineum) (Reasoning: Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.)

The nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication? A. Muscle irritability within 1 hour of birth B. Neurologic signs during the first 24 hours C. Jaundice that develops in the first 12 to 24 hours D. Jaundice that develops between 48 and 72 hours after birth

C (Jaundice that develops in the first 12 to 24 hours) (Explanation: The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Neurologic signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL (100 mcmol/L) the second to third day when jaundice appears (physiologic jaundice).)

Which instruction does the nurse give to a client who arrives in the birthing room with the fetal head crowning? A. Push forcefully. B. Turn to the left side. C. Use the pant-breathing pattern. D. Assume the knee-chest position.

C (Use the pant-breathing pattern.) (Reasoning: Panting will slow the process so the nurse can support the head as the baby is born. Pushing will speed the birth, which could result in injury to both mother and fetus. Turning the mother on her left side will have no effect on the progress of the second stage of labor, and it is difficult to accomplish when the fetal head is crowning. Having the mother assume the knee-chest position will have no effect on the progress of the second stage of labor, and it is difficult to accomplish when the fetal head is crowning.)

Which condition is most commonly associated with late decelerations of the fetal heart rate? A. Head compression B. Maternal hypothyroidism C. Uteroplacental insufficiency D. Umbilical cord compression

C (Uteroplacental insufficiency) (Reasoning: Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.)

Which client is at increased risk for postpartum hemorrhage? A. One who breast-feeds in the birthing room B. One who receives a pudendal block for the birth C. One whose third stage lasts less than 10 minutes D. One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

D (One who gives birth to an infant weighing 9 lb 8 oz) (Reasoning: The risk for a postpartum hemorrhage is greater with large infants, because the uterine musculature has been stretched excessively, thus impairing the ability of the uterus to contract after the birth. Early breast-feeding stimulates uterine contractions and lessens the chance of hemorrhage. Having a pudendal block for the birth does not contribute to the risk for postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. A third stage of labor lasting less than 10 minutes is a short third stage; a prolonged third stage of labor, 30 minutes or longer, could increase the risk of postpartum hemorrhage.)

Which food contains at least 100 mcg of folate per serving? Select all that apply. One, some, or all responses may be correct. A. Bread B. Broccoli C. Cooked pasta D. Black-eyed peas E. Ready-to-eat breakfast cereal

D and E (black eyed peas and ready to eat breakfast cereal) (Reasoning: Neural tube defects (NTDs), or failures in closure of the neural tube, are more common in infants of women with poor folic acid intake. Proper closure of the neural tube is required for normal formation of the spinal cord, and the neural tube begins to close within the first month of gestation, often before a person realizes she is pregnant. Therefore, all people who are capable of becoming pregnant should take 0.4 mg of folic acid every day, in addition to consuming dietary sources of folate. One-half cup of black-eyed peas contains at least 100 mcg of folate. Ready-to-eat breakfast cereal contains 200 mcg of folate. A slice of bread contains 20 mcg, not 100 mcg of folate. One-half cup of broccoli and a cup of pasta contain 50 mcg, not 100 mcg of folate.)

During a nonstress test, the baseline fetal heart rate of 130 to 140 beats per minute rises to 160 twice and 157 once during a 20-minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take? A. Discontinue the test because the pattern is within the normal range. B. Encourage the client to drink more fluids to decrease fetal heart rate. C. Notify the primary health care provider and prepare for an emergency birth. D. Record this nonreassuring pattern and continue the test for further evaluation.

A ( Discontinue the test because the pattern is within the normal range.) (Reasoning: The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being.)

Which common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? A. Intrusion on movement B. Inability to take sedatives C. Interference with breathing techniques D. Increased frequency of vaginal examinations

A (Intrusion on movement) (Reasoning: Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.)

The nurse enters the client's room and observes the infant lying quietly in the bassinet with the eyes open wide. Which action would the nurse take in response to the infant's behavior? A. Brightening the lights in the room B. Encouraging the mother to talk to her baby C. Wrapping and then turning the infant to the side D. Beginning physical and behavioral assessments

B (Encouraging the mother to talk to her baby) (Explanation: A quiet, alert state is an optimal time for infant stimulation. Bright lights are disturbing to newborns and may impede mother-infant interaction. Wrapping and then turning the infant to the side is done for the sleeping infant. Physical and behavioral assessments are not the priorities; they may be delayed.)

One hour after a birth the nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and 2 fingerbreadths below the umbilicus. Which would the nurse do next? A. Encourage the client to void. B. Notify the health care provider immediately. C. Massage the uterus and attempt to express clots. D. Continue periodic assessments and record the findings.

D (Continue periodic assessments and record the findings) (Reasoning: Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded.)

Which suggestion would the nurse make to a client with morning sickness? A. "Eat dry crackers before you get out of bed. B. "Increase your fat intake before bedtime." C. "Drink high-carbohydrate fluids with meals." D. "Eat 2 small meals a day and a snack at noon."

A ("Eat dry crackers before you get out of bed.) (Reasoning: Nausea and vomiting in the morning occur in almost 50% of all pregnancies. Eating dry crackers before getting out of bed in the morning is a simple remedy that may provide relief. Separating fluids from solids at mealtime is more advisable. Eating 2 small meals a day and a snack at noon does not meet the nutritional needs of a pregnant woman, nor will it relieve nausea. Some women find that eating 5 or 6 small meals daily instead of three large ones is helpful.)

An adolescent gives birth to an infant with a severe cleft lip and palate who is immediately placed on the radiant warmer. After ensuring that there is an adequate airway, the nurse gives the newborn to the mother. Which response to the infant would the nurse anticipate? A. "I don't believe it. This can't be my baby!" B. "I'm so sad. Do you think I'm being punished?" C. "My parents will be so upset. What could have happened?" D. "I shouldn't have had this baby! Now my boyfriend won't marry me."

A ("I don't believe it. This can't be my baby!") (Explanation: Denial or disbelief and shock are considered initial grieving responses. There is a feeling of guilt and inadequacy when an infant is born with a defect. It is unusual for a client to initially verbalize feelings of punishment or guilt so directly. A sense of shame and guilt is voiced later, after denial, disbelief, and shock have occurred. It is unusual for a client to use rationalization and voice it so obviously.)

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During an NST, the client asks what it means when the fetal heart rate goes up every time the fetus moves. Which is an appropriate response? A. "These accelerations are a sign of fetal well-being." B. "These accelerations indicate fetal head compression." C. "Umbilical cord compression is causing these accelerations." D. "Uteroplacental insufficiency is causing these accelerations."

A ("These accelerations are a sign of fetal well-being.") (Reasoning: The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.)

Which recommendation would the nurse make to a pregnant client who sits almost continuously during her working hours? A. "Try to walk around every few hours during the workday." B. "Ask for time in the morning and afternoon to elevate your legs." C. "Tell your boss that you won't be able to work beyond the second trimester." D. "Ask for time in the morning and afternoon so you can go get something to eat."

A ("Try to walk around every few hours during the workday.") (Reasoning: Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly those in the popliteal spaces, and may diminish venous return. Walking causes the leg muscles to contract and applies gentle pressure to the veins, thereby promoting venous return. Walking around several times each morning and afternoon will improve circulation; the legs may be elevated while the client is sitting at her desk. If the client is feeling well, there are no contraindications to working throughout her pregnancy. Adequate nourishment can be obtained during mealtimes; the client does not require extra nutrition breaks.)

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action? A. Administering oxygen B. Elevating the head of the bed C. Drawing blood for a hematocrit level D. Giving an intramuscular analgesic

A (Administering O2) (Reasoning: Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary health care provider's prescription.)

Which factor distinguishes true labor from false labor? A. Cervical dilation is evident. B. Contractions stop when the client walks around. C. The client's contractions progress only when she is in a side-lying position. D. Contractions occur immediately after the membranes rupture

A (Cervical dilation is evident) (Reasoning: Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions will increase with activity. Contractions of true labor persist in any position. Contractions may not begin until 24 to 48 hours after the membranes rupture.)

Which action would the nurse take when a client's membranes rupture while her labor is being augmented with an oxytocin infusion and variable decelerations in the fetal heart rate occur? A. Change the client's position. B. Take the client's blood pressure. C. Stop the client's oxytocin infusion. D. Prepare the client for an immediate birth

A (Change the client's position.) (Reasoning: Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure or to the oxytocin. Preparing the client for an immediate birth is premature; other nursing measures should be tried first.)

A pregnant client is admitted to the high-risk unit with abruptio placentae. Which priority assessment would be included with vital signs, skin color, urine output, and fetal heart rate? A. Fundal height B. Obstetric history C. Time of last meal D. History of bleeding tendencies

A (Fundal height) (Reasoning: It is vital that a baseline measurement of the height of the fundus be obtained, because increasing size is an indication of concealed hemorrhage; with abruptio placentae, bleeding occurs behind the placenta. Obstetric history, time of the last meal, and history of bleeding tendencies are all appropriate assessment questions; however, none are a priority at this time.)

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action would the nurse implement at this time? A. Having her pant-blow during contractions B. Placing her legs in stirrups to facilitate pushing C. Encouraging her to bear down with each contraction D. Reviewing the pushing techniques taught in childbirth classes

A (Having her pant-blow during contractions) (Reasoning: Although there are exceptions, the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing. Pushing may cause cervical trauma when the cervix is not completely dilated. It is too early to prepare for the second stage of labor or to have the client bear down with each contraction if the cervix is not fully dilated. At this time the client is completely introverted and will be unreceptive to a review of pushing techniques.)

While caring for a client during labor, which would the nurse remember about the second stage of labor? A. It ends at the time of birth. B. It ends as the placenta is expelled. C. It begins with the transition phase of labor. D. It begins with the onset of strong contractions

A (It ends at the time of birth) (Reasoning: The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.)

Which factor in a client's history indicates an increased risk for postpartum hemorrhage? A. Multifetal pregnancy B. Short duration of labor C. Previous cesarean birth D. Age older than 40 years

A (Multifetal pregnancy) (Reasoning: Overdistention of the uterus because of a large fetus, multiple gestation, or hydramnios predisposes a woman to uterine atony, which may cause postpartum hemorrhage. A short duration of labor may lead to a precipitous birth, which is potentially harmful to the fetus but does not affect uterine contractions after the birth. Previous cesarean birth is not related; unless uterine atony is present, hemorrhage should not occur. Age older than 40 years is not a factor in involution of the uterus.)

Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck? A. Nevi B. Desquamation C. Mongolian spots D. Erythema toxicum

A (Nevi) (Explanation: Nevi, described as small, flat pink spots, are the result of a superficial capillary defect and are most commonly found on the upper eyelids, nose, upper lip, and nape of the neck. Desquamation is peeling skin that occurs a few days after birth. Mongolian spots are bluish-black areas of pigmentation. Erythema toxicum is a transient rash that appears 24 to 72 hours after birth that can last up to 3 weeks of age.)

An infant born at 36 weeks' gestation weighs 4 lb 3 oz (1899 g) and has Apgar scores of 7 and 9. Which nursing action(s) will be performed upon the infant's admission to the nursery? Select all that apply. One, some, or all responses may be correct. A. Recording the neonate's vital signs B. Administration of nasal cannula oxygen C. Offering a bottle of dextrose in water D. Evaluation of the neonate's health status E. Keeping the neonate's body warm

A (Recording the neonate's vital signs), D (Evaluation of the neonate's health status), E (keeping the neonate warm) (Explanation: Recording of vital signs is an important part of recordkeeping for all newborns. All newborns are evaluated on their admission to the nursery. All newborns should be kept warm to maintain a stable body temperature. The neonate's Apgar scores (7 and 9) do not indicate a need for oxygen. Newborns are either breast-fed or formula-fed; glucose water is not offered first even for infants with a low blood glucose level. In those cases, glucose is given intravenously.)

For which reason would the nurse encourage a client to void during the first stage of labor? A. A full bladder is often injured during labor. B. A full bladder may inhibit the progress of labor. C. A full bladder jeopardizes the status of the fetus. D. A full bladder predisposes the client to urinary infection.

B (A full bladder may inhibit the progress of labor) (Reasoning: A full bladder inhibits the progress of labor by encroaching on the uterine space and impeding the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.)

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. Which is the next nursing action? A. Calling the primary health care provider B. Changing the maternal position C. Obtaining the maternal blood pressure D. Preparing the environment for an immediate birth

B (Changing the maternal position) (Reasoning: The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth.)

Which is the most appropriate nursing intervention for a client admitted to the high-risk prenatal unit at 35 weeks' gestation with a diagnosis of complete placenta previa? A. Applying a pad to the perineal area B. Having oxygen available at the bedside C. Allowing bathroom privileges with assistance D. Educating the client regarding the intensive care nursery

B (Having oxygen available at the bedside) (Reasoning: If hemorrhage should occur, oxygen is necessary to prevent maternal and fetal compromise. A perineal pad is not necessary; close monitoring is required. The client admitted with a complete placenta previa is usually on complete bed rest. It is too soon to discuss the neonatal intensive care unit, because this may ultimately be unnecessary.)

Which action would the nurse take to prevent the loss of heat through convection in a newborn? A. Dry the infant immediately after birth. B. Keep the infant's crib away from the window. C. Cover the scale before weighing the infant. D. Wrap the infant in blankets, and place a cap on the head.

B (Keep the infant's crib away from the window.) (Explanation: The crib should be kept away from the window to prevent heat loss through convection. The scale should be covered before weighing the infant to prevent heat loss through conduction. The infant should be thoroughly dried after birth and wrapped in blankets with a cap placed on the head to prevent heat loss through evaporation.)

Which nursing intervention holds the highest priority for a client with class I heart disease during the postpartum period? A. Promoting early ambulation B. Watching for signs of cardiac decompensation C. Assessing the mother's emotional reaction to the birth D. Instructing the mother about activity levels during the postpartum period

B (Watching for signs of cardiac decompensation) (Reasoning: Cardiac decompensation may occur because of the increased circulating blood volume during the early postpartum period, which requires increased cardiac function. Although promotion of early ambulation, assessing the mother's emotional reaction to the birth, and instructing the mother regarding activity during the postpartum period are all important, they are not the priority.)

After teaching the parents of a newborn how to suction using a bulb syringe, which statement made by the parent indicates an understanding of the information? A. "I will suction the nares first." B. "I will keep the bulb syringe nearby." C. "I will depress the bulb before suctioning the mouth or nose." D. "I will insert the tip of the bulb syringe in the center of the mouth."

C ("I will depress the bulb before suctioning the mouth or nose.") (Explanation: The bulb syringe is depressed before suctioning the mouth or the nose. The mouth should be suctioned first. The bulb should be kept in the crib at all times. When suctioning the mouth, the tip of the bulb should be inserted into one side of the mouth to avoid stimulating the gag reflex.)

After treatment for a bladder infection, a client asks whether there is anything she can do to prevent cystitis in the future. Which response would the nurse give? A. "Avoid regular use of tampons." B. "Decrease your intake of prune juice." C. "Increase your daily fluid consumption." D. "Cleanse the perineum from back to front."

C ("Increase your daily fluid consumption.") (Explanation: Increasing fluid intake flushes the urinary tract of microorganisms. Use of tampons does not increase the risk of cystitis. Fluid consumption should be increased, not decreased. The preferred method of cleansing is from front to back (urethra to vagina); however, studies have shown that this method of cleansing is not a significant factor in the prevention of cystitis.)

The nurse is teaching a prenatal class regarding infant safety. Which statement made by a future parent indicates effective teaching? A. "My mother has already made the cutest pillowcases for the baby's pillows." B. "I just bought a new baby seat that can be strapped into the front seat of the car." C. "My mother can't believe that babies are supposed to sleep on their backs, not their stomachs." D. "At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."

C ("My mother can't believe that babies are supposed to sleep on their backs, not their stomachs.") (Explanation: Research demonstrates that placing an infant on the back reduces the incidence of sudden infant death syndrome (SIDS). Pillows in an infant's crib can cause suffocation. It is unsafe to strap an infant seat into the front seat of a car. An infant can drown in a very small amount of water in a tub; it is unsafe to leave an infant alone in a tub.)

Between which weeks of gestation would a client with type 1 diabetes expect to increase her insulin dosage? A. 10th and 12th weeks of gestation B. 18th and 22nd weeks of gestation C. 24th and 28th weeks of gestation D. 36th and 40th weeks of gestation

C (24th and 28th weeks of gestation) (Reasoning: At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases, and insulin needs decrease accordingly.)

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with her or his own feelings regarding abortion, death, and loss to be able to do which? A. Maintain control of the situation B. Share personal grief with the client C. Allow the client to express her grief D. Teach the client how to cope effectively

C (Allow the client to express her grief) (Reasoning: The nurse can be more sensitive to the needs of the client by addressing personal emotions first. Control is not, and should not be, the goal of the nurse. The client's feelings, not the nurse's, should be the focus. A time of crisis is not the time to teach; the client is not ready to learn.)

When assessing a client who gave birth 1 day ago, the nurse finds the fundus is firm at 1 fingerbreadth below the umbilicus and the perineal pad is saturated with lochia rubra. Which is the nurse's next action? A. Recording these expected findings B. Obtaining a prescription for an oxytocic medication C. Asking the client when she last changed the perineal pad D. Notifying the primary health care provider of excessive bleeding

C (Asking the client when she last changed the perineal pad)

Which is the immediate nursing action when a client's membranes rupture spontaneously, releasing clear, odorless fluid? A. Change the bedding. B. Notify the practitioner. C. Assess the fetal heart rate (FHR). D. Obtain the client's blood pressure.

C (Assess the fetal heart rate (FHR)) (Reasoning: The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, addressing comfort by changing the bedding is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.)

Which assessment finding is most significant in an infant of a diabetic mother (IDM) who is large for gestational age (LGA)? A. Temperature less than 98°F (36.6°C) B. Heart rate of 110 beats/min C. Blood glucose level less than 40 mg/dL (2.2 mmol/L) D. Increasing bilirubin during the first 24 hours

C (Blood glucose level less than 40 mg/dL (2.2 mmol/L)) (Reasoning: At birth, circulating maternal glucose is removed; however, the IDM still has a high level of insulin, and rebound hypoglycemia may develop. The temperature-regulating ability of an IDM is similar to that of a healthy neonate, unless the IDM is preterm. A heart rate of 110 beats/min is within the expected range for a newborn. Pathologic jaundice is associated with hemolytic diseases such as Rh and ABO incompatibilities and sepsis, not maternal diabetes.)

Which information about adolescent growth and development would the nurse need to understand before discussing changes in body size to a 16-year-old adolescent at 24 weeks' gestation? A. Adolescents generally regain their figures 2 weeks after the birth, so size is of moderate concern. B. Adolescents are in a high-risk category, so weight gain should be limited to prevent complications. C. Body image is very important to adolescents; therefore, pregnant teenagers are overly concerned about body size. D. Physiological growth in adolescents is more rapid than in adults, so the gravid size is larger than that of an adult woman.

C (Body image is very important to adolescents; therefore, pregnant teenagers are overly concerned about body size.) (Reasoning: Because of the changes in body size, the pregnant adolescent may feel insecure as she struggles to establish her identity. There are no data to support the statement that adolescents generally regain their figures 2 weeks after the birth. The optimal weight gain for an adolescent is at the upper range for her body mass index; this will help prevent complications, so limiting weight gain does not prevent complications. Although physiological growth is rapid, the adolescent's gravid size falls within the expected parameters for pregnant women and is not larger than that of adult women.)

Which type of isolation precautions would the postpartum nurse plan to institute for a client who has delivered her infant by cesarean birth because of active genital herpes? A. Enteric B. Droplet C. Contact D. Airborne

C (Contact) (Reasoning: Contact precautions include a gown, mask, and gloves to protect the nurse from the virus; the client should be in a private room. The Centers for Disease Control and Prevention guidelines for isolation precautions do not include enteric precautions as a category. Droplet and airborne precautions are not necessary for a person with genital herpes.)

Which action provides support for the fetal head as it is being delivered? A. Applying suprapubic pressure B. Placing a hand firmly against the perineum C. Distributing the fingers evenly around the head D. Maintaining pressure against the anterior fontanelle

C (Distributing the fingers evenly around the head) (Reasoning: Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.)

Which intervention would the nurse initiate when a fetal heart pattern signifying uteroplacental insufficiency occurs? A. Inserting a urinary catheter B. Administering oxygen by means of nasal cannula C. Helping the client turn to the side-lying position D. Encouraging the client to pant with her next contraction

C (Helping the client turn to the side-lying position) (Reasoning: Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urinary catheter is unnecessary; in addition, it requires a primary health care provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.)

Which type of lochia would the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? A. Scant alba B. Scant rubra C. Moderate rubra D. Moderate serosa

C (Moderate rubra) (Reasoning: The uterus sloughs off the blood, tissue, and mucus of the endometrium postdelivery. This happens in 3 stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that is expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for about 7 days.

Which factor contraindicates sexual intercourse during pregnancy? A. Fetal tachycardia B. Presence of leukorrhea C. Premature rupture of membranes D. Imminence of the estimated date of birth

C (Premature rupture of membranes) (Reasoning: Ruptured membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common because of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. Intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed because of the enlarged abdomen.)

Which of these presentations would indicate that the nurse should direct a primipara to call a health care provider? A. Bloody show or back pressure occurring with no contractions B. Irregular contractions coming 10 minutes apart C. Rupture of membranes or contractions 5 minutes apart D. Contractions 12 minutes apart and lasting about 30 seconds

C (Rupture of membranes or contractions 5 minutes apart) (Reasoning: When the membranes rupture, the potential for infection is increased, and when the contractions are 5 to 8 minutes apart, they are usually of sufficient force to warrant professional supervision. Bloody show and back pressure may be early signs of labor or signs of posterior fetal position; however, it is too early to notify the health care provider. Irregular contractions coming 10 minutes apart and contractions 12 minutes apart and lasting about 30 seconds indicate that it is too soon in the labor process to call the health care provider; the client should remain with her family and keep moving around at home.)

How would an Apgar score recorded 5 minutes after birth assist the nurse in evaluating the care of the newborn? A. Gestational age of the newborn B. Effectiveness of the birthing process C. Possibility of respiratory distress syndrome D. Adequacy of the transition to extrauterine life

D (Adequacy of the transition to extrauterine life) (Explanation: The score at 5 minutes indicates the adequacy of the cardiac and respiratory systems' response to the environment. The Dubowitz score is related to gestational age. The Apgar score represents the neonate's response to the environment and is not related to the actual process of labor and birth. The Apgar score is not a diagnostic tool for respiratory distress syndrome.)

Which finding in a newborn whose temperature over the past 4 hours has fluctuated between 98.0°F (36.7°C) and 97.4°F (36.3°C) would be considered critical? A. Respiratory rate of 60 breaths/min B. White blood count greater than 15,000 mm3 C. Serum calcium level of 8 mg/dL (2 mmol/L) D. Blood glucose level of 26 mg/dL (1.4 mmol/L)

D (Blood glucose level of 26 mg/dL (1.4 mmol/L)) (Explanation: Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 30 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm3 are all normal findings and do not affect body temperature.)

Which would evidence of the Babinski reflex indicate during a newborn assessment? A. Hypoxia during labor B. Neurological injury during birth C. Hyperreflexia of the muscular system D. Immaturity of the central nervous system (CNS)

D (Immaturity of the central nervous system (CNS)) (Explanation: Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. The newborn would not elicit the Babinski reflex if there were neurological injury during birth. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.)

The client is in labor with a fetus in the breech presentation. Which assessment finding would the nurse expect? A. Hemorrhagic shock B. Increased blood pressure C. Compression of the cord D. Meconium in the amniotic fluid

D (Meconium in the amniotic fluid) (Reasoning: Meconium in the amniotic fluid is common with a breech presentation because as the fetus's buttocks are compressed with labor progression, meconium may be expelled. The risk of hemorrhagic shock and increased blood pressure are no greater in a breech presentation than in a cephalic presentation. The umbilical cord may prolapse after the membranes rupture, and pressure of the presenting part on the cord could compress the cord, resulting in fetal hypoxia. However, this would not be found in most cases.)

Which physiological changes would the nurse anticipate after an amniotomy is performed? A. Diminished bloody show B. Increased and more variable fetal heart rate C. Less discomfort with contractions D. Progressive dilation and effacement

D (Progressive dilation and effacement) (Reasoning: Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding (bloody show) may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after the membranes are artificially ruptured.)

Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?

gamma globulins (Explanation: The gamma globulin antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered.)

Lochia serosa is the ___________ stage of postpartum bleeding and is thinner in consistency and __________________ in color. Lochia serosa typically lasts about ___________, although for some women it can last up to 4 to 6 weeks postpartum.

second; brownish or pink; 2 weeks