Mother Baby Final Exam

The nurse is discussing colonoscopies with a female client. The nurse explains that the client should have a colonoscopy every _____ year(s) after age _____ (Fill in the blank).

10 50

The nurse is discussing bone density tests with a female client. The nurse explains that the client should have a bone density test every _____ year(s) starting at age ____ (Fill in the blank).

2 65

The nurse is discussing fasting glucose testing with a female client. The nurse explains that testing for diabetes mellitus is recommended every _____ years after age _____ or earlier if the woman has high-risk factors such as family history or being overweight (Fill in the blank).

3 45

Which position should the preterm infant be placed in to facilitate drainage of respiratory secretions (Fill in the blank)?

Prone or side-lying Rationale: Normal newborn infants should not be placed in these positions because they are associated with an increased incidence of sudden infant death syndrome (SIDS). In the preterm infant, however, the prone position increases oxygenation, enhances respiratory control, improves lung mechanics and volume, and reduces energy expenditure.

A nurse is caring for a client with uterine inversion. How often should the nurse assess the client's vital signs? a. every 15 minutes b. every 30 minutes c. every 1 hour d. every 2 hours

Rationale: The nurse should assess vital signs every 15 minutes or more frequently until the client is stable.

The nurse is teaching a group of newly licensed nurses about critical clinical practices called safety bundles. The nurse explains that these practices fall into which four categories (Fill in the blank)?

Readiness Recognition and Prevention Response Reporting and System Learning

A woman asks the nurse to explain why an incompetent cervix has caused her to lose two pregnancies. The best response is: a. "As the baby grows, your cervix doesn't stay closed to keep the baby in the uterus." b. "Your cervix is closed so tightly that adequate blood can't reach the baby." c. "Your cervix is not allowing enough sperm to reach the ovum." d. "Your uterus is more irritable because of scarring on the cervix."

a. "As the baby grows, your cervix doesn't stay closed to keep the baby in the uterus." Rationale: An incompetent cervix dilates painlessly, usually during the second trimester when the fetus is heavier, causing spontaneous abortion. The cervix begins to dilate, it does not stay closed. The woman has achieved pregnancy, so the sperm was able to reach the ovum. An irritable uterus is not associated with an incompetent cervix.

A nurse is providing home management teaching for a client who is at 28 weeks of gestation and recently had a premature rupture of membranes (PROM). Which statements by the client indicate that the teaching was effective (Select all that apply)? a. "I should avoid sexual intercourse, orgasm, or insertion of anything into my vagina as it could increase my risk for infection." b. "I should avoid breast stimulation because it could stimulate contractions." c. "I should note and report uterine contractions or a foul odor to vaginal drainage." d. "I should take my temperature once a day and report a temperature of more than 102.2°F." e. "I should maintain the activity restrictions that my provider gave me."

a. "I should avoid sexual intercourse, orgasm, or insertion of anything into my vagina as it could increase my risk for infection." b. "I should avoid breast stimulation because it could stimulate contractions." c. "I should note and report uterine contractions or a foul odor to vaginal drainage." e. "I should maintain the activity restrictions that my provider gave me." Rationale: The client should take her temperature at least four times a day and report a temperature of more than 100°F.

A nurse is providing teaching to a client who is prescribed methotrexate for an ectopic pregnancy. Which statements by the client indicate that the teaching was effective (Select all that apply)? a. "I should flush the toilet twice with the lid closed when I urinate." b. "I may experience nausea and vomiting." c. "I can drink as much alcohol as I did before I was pregnant." d. "If the treatment is successful, the beta-hCG in my blood will disappear within 1 week." e. "I may experience transient abdominal pain."

a. "I should flush the toilet twice with the lid closed when I urinate." b. "I may experience nausea and vomiting." e. "I may experience transient abdominal pain." Rationale: The client should be instructed to avoid alcohol as it can decrease the effectiveness of methotrexate. If the treatment is successful, beta-hCG should disappear from plasma within 2-3 weeks.

A client who had a modified biophysical profile (MBPP) is told that the amniotic fluid amount is 12 cm. She asks the nurse what this means. The nurse's best response is: a. "This is reassuring and indicates your baby is well oxygenated." b. "This is lower than normal and indicates that your baby has oligohydramnios." c. "This is higher than normal and indicates that your baby has hydramnios." d. "This means that the results are inconclusive and the test needs to be performed again."

a. "This is reassuring and indicates your baby is well oxygenated." Rationale: A score of 10 cm or greater is reassuring. A score of less than 5 cm indicates oligohydramnios. A score of higher than 18 to 20 cm indicates hydramnios. This does not indicate that the test is inconclusive.

The nurse is preparing to administer IV fluids to a dehydrated preterm infant. The nurse know that fluid should be administered with a precision of _____ mL/h. a. 0.01 b. 0.05 c. 0.5 d. 1

a. 0.01 Rationale: IV fluids should be carefully regulated using infusion control devices that administer fluid with a precision of 0.01 mL/h to help prevent fluid overload.

A nurse preceptor is assessing a newly licensed nurse's knowledge of lochia. The newly licensed nurse displays proper knowledge by stating "Saturation of one peripad in _____ represents excessive blood loss". a. 15 minutes b. 30 minutes c. 45 minutes d. 1 hour

a. 15 minutes Rationale: Lochia should be dark red and scant to moderate in amount. Saturation of one peripad In 15 minutes represents excessive blood loss.

A nurse receiving a handoff report is told that her client experienced a precipitous labor. The nurse knows that this means that the client delivered her baby within ____ of the onset of labor. a. 3 hours b. 4 hours c. 5 hours d. 6 hours

a. 3 hours Rationale: During precipitous labor, intense contractions often begin abruptly and birth occurs within 3 hours of onset of labor.

A nurse is assessing a client who has premature rupture of membranes (PROM). The nurse knows that conditions associated with PROM include (Select all that apply): a. Triple I b. macrosomia c. maternal stress d. low socioeconomic status e. incompetent cervix

a. Triple I c. maternal stress d. low socioeconomic status e. incompetent cervix Rationale: Conditions associated with PROM include Triple I. maternal stress, low socioeconomic status, incompetent cervix, infections, amniotic sac with a weak structure, previous preterm birth, fetal abnormalities or malpresentation, overdistention of the uterus, maternal hormonal changes, and maternal nutritional deficiencies and diabetes.

A nurse preceptor is teaching a newly licensed nurse about clinical manifestations of uterine atony. Which clinical manifestations should be included (Select all that apply)? a. a uterine fundus that is difficult to locate b. a fundus that is below the expected level c. excessive bright red lochia d. a soft or boggy fundus e. excessive clots expelled

a. a uterine fundus that is difficult to locate c. excessive bright red lochia d. a soft or boggy fundus e. excessive clots expelled Rationale: Major signs of uterine atony include a fundus that is difficult to locate, a soft or boggy uterus, a uterus that becomes firm as it is massaged but loses its tone when massage is stopped, a fundus that is located ABOVE the expected level, excessive bright red lochia, and excessive clots expelled.

A nurse is assessing a client with a suspected ectopic pregnancy. The nurse knows to look for the following manifestations (Select all that apply): a. abdominal pain b. shoulder pain c. chest pain d. unusual weight gain e. vaginal spotting

a. abdominal pain b. shoulder pain e. vaginal spotting Rationale: Neither chest pain nor unusual weight gain are manifestations of ectopic pregnancy.

Which assessment finding would convince the nurse to hold the next dose of magnesium sulfate? a. absence of deep tendon reflexes (DTRs) b. urinary output of 100 mL total for the previous 2 hours c. respiratory rate of 14 breaths per minute d. decrease in blood pressure from 160/100 to 145/85

a. absence of deep tendon reflexes (DTRs) Rationale: Because absence of DTRs is a sign of magnesium toxicity, the next scheduled dose should not be administered. Calcium gluconate is the antidote that should be administered. An hourly output of less than 30 mL could indicate toxicity. A respiratory rate of less than 12 breaths per minute could indicate toxicity. Decrease in blood pressure is an expected side effect of magnesium sulfate.

The nurse is assessing an infant for retinopathy of prematurity (ROP). The nurse knows that which of the following are risk factors for ROP (Select all that apply)? a. acidosis b. inadequate ventilation c. low levels of oxygen d. intraventricular hemorrhage e. shock

a. acidosis d. intraventricular hemorrhage e. shock Rationale: The cause of ROP is unknown, but HIGH LEVELS OF OXYGEN in the blood are a risk factor. Other risk factors include PROLONGED VENTILATION, acidosis, sepsis, shock, and intraventricular hemorrhage.

A client at 21 weeks of gestation is diagnosed with chronic hypertension. The nurse knows that risk factors for chronic hypertension include (Select all that apply): a. advanced maternal age b. underweight c. diabetes d. African-American race e. renal disease

a. advanced maternal age c. diabetes d. African-American race e. renal disease Rationale: Risk factors for chronic hypertension include advanced maternal age, OBESITY, diabetes, African-American race, and renal disease.

The nurse is assessing an infant with persistent pulmonary hypertension of the newborn (PPHN). Which problem should the nurse assess for? a. anemia b. metabolic alkalosis c. hypercalcemia d. hyperglycemia

a. anemia Rationale: Assessment for HYPOGLYCEMIA, HYPOCALCEMIA, anemia, and metabolic ACIDOSIS is important.

The nurse is caring for a client with rheumatic heart disease who is at 22 weeks of gestation and has developed mitral stenosis. The nurse knows that this patient may be at risk for developing (Select all that apply): a. aortic regurgitation b. congestive heart failure c. atrial fibrillation d. peripheral edema e. pulmonary hypertension

a. aortic regurgitation b. congestive heart failure c. atrial fibrillation e. pulmonary hypertension Rationale: Pregnant clients with mitral stenosis are at increased risk for developing aortic regurgitation, congestive heart failure, atrial fibrillation, and PULMONARY EDEMA.

The nurse is assessing a client at risk for placental abruption. The nurse knows that the major dangers to the fetus are (Select all that apply): a. asphyxia b. hypertension c. excessive blood loss d. prematurity e. deep vein thrombosis

a. asphyxia c. excessive blood loss d. prematurity Rationale: Neither hypertension nor deep vein thrombosis are dangers for the fetus during a placental abruption. Dangers to the mother include hemorrhage and consequent hypovolemic shock and clotting abnormalities.

A client has been in active labor for 17 hours. Which of the following measures could the nurse take at this time? a. assess for infection b. encourage the client to stay in the same position c. start discharge teaching d. encourage the client to start pushing now

a. assess for infection Rationale: Although the client should conserve energy, if the position she is in is contributing to the length of labor, a position change may be necessary. The client is most likely very stressed and in no state to receive teaching. Encouraging the client to push before it is time could result in laceration and maternal exhaustion. Other measures include promotion of comfort and emotional support.

A client in the second stage of labor is having trouble delivering her macrosomic baby. Which intervention is appropriate for the nurse to take at this time? a. assist the client onto a labor ball b. assist the client into a supine position c. request an epidural d. prepare for an emergency cesarean

a. assist the client onto a labor ball Rationale: Assisting the client onto a labor ball can cause the pelvic diameter to increase, which will help progress the delivery. A supine position is contraindicated as it could cause hypotension and slowing of delivery. An epidural at this time is contraindicated as the patient is in the second stage of labor. Although a cesarean may be indicated later in the delivery, this is not an appropriate intervention at this time.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding progestin injections (Depo-Provera) (Select all that apply)? a. avoids need for daily use b. requires use only once a year c. no side effects d. may decrease menstrual bleeding e. protects against STDs

a. avoids need for daily use d. may decrease menstrual bleeding Rationale: Depo-Provera requires use only ONCE EVERY 12 WEEKS. Depo-Provera have SIDE EFFECTS SIMILAR TO THOSE OF OTHER PROGESTIN CONTRACEPTIVES. Depo-Provera DOES NOT protect against STDs.

The experienced nurse is reviewing transmission of infection with a group of newly licensed nurses. The experienced nurse knows that the newly licensed nurses understand the review when they state that vertical infection is acquired (Select all that apply): a. before birth b. during birth c. after birth

a. before birth b. during birth Rationale: Vertical infection is acquired before or during birth from the mother. Organisms such as those causing rubella, cytomegalovirus, syphilis, HIV, and toxoplasmosis may cross the placenta and cause infection during pregnancy.

The nurse is assessing an infant with suspected necrotizing enterocolitis (NEC). Which manifestations should the nurse look for (Select all that apply)? a. bile-stained emesis b. hypertension c. bradycardia d. hyperactive bowel sounds e. sunken abdomen

a. bile-stained emesis c. bradycardia Rationale: Signs and symptoms of NEC include ABDOMINAL DISTENTION, HYPOACTIVE BOWEL SOUNDS, vomiting, bile-stained emesis, abdominal tenderness and discoloration, signs of infection, occult blood in stool, apnea, bradycardia, temperature instability, lethargy, HYPOTENSION, and shock.

A nurse is caring for a client with pregnancy-related anaphylactoid syndrome. The nurse knows that therapeutic management includes (Select all that apply): a. blood component therapy to correct coagulation defects b. oxygen with mechanical ventilation c. correction of hypertension d. cardiopulmonary resuscitation and support e. administration of metoprolol

a. blood component therapy to correct coagulation defects b. oxygen with mechanical ventilation d. cardiopulmonary resuscitation and support Rationale: The client with pregnancy-related anaphylactoid syndrome might experience hypotension, not hypertension. There is evidence to suggest that administration of atropine to correct bradycardia may be useful in managing pregnancy-related anaphylactoid syndrome. Metoprolol is a beta-blocker used to slow down the heart rate and would be contraindicated.

A client is scheduled to have a surgical biopsy to remove a lump of breast tissue. The nurse knows that which of the following conditions may warrant this type of biopsy (Select all that apply)? a. bloody fluid aspirated from a cyst b. nipple ulceration c. solid dominant mass diagnosed as fibroadenoma d. recurrence of the cyst after 3 or more aspirations e. suspicious mass that persists through a menstrual cycle

a. bloody fluid aspirated from a cyst b. nipple ulceration e. suspicious mass that persists through a menstrual cycle Rationale: Open, or surgical, biopsy is performed to remove all or part of the lump of breast tissue if the following conditions exist: suspicious mass that persists through a menstrual cycle; bloody fluid aspirated from a cyst; failure of the mass to disappear completely after fluid aspiration; recurrence of the cyst after ONE OR TWO ASPIRATIONS; solid dominant mass NOT diagnosed as fibroadenoma; serous or serosanguineous nipple discharge; nipple ulceration or persistent crusting; skin edema and erythema suspicious for inflammatory breast carcinoma; suspicious mammography or ultrasound findings; known or possible genetic abnormality that increases a woman's risk for breast cancer.

A nurse is assessing a client at risk for placental abruption. The nurse knows to look for the following manifestations (Select all that apply): a. board-like abdomen b. low uterine resting tone c. dull abdominal or low back back pain d. uterine irritability with frequently high-intensity contractions e. purulent amniotic fluid

a. board-like abdomen c. dull abdominal or low back back pain Rationale: Manifestations of placental abruption include HIGH UTERINE RESTING TONE, uterine irritability with frequently LOW-INTENSITY CONTRACTIONS, PORT WINE-COLORED AMNIOTIC FLUID, nonreassuring FHR patterns, signs of hypovolemic shock, and bleeding which may be evident vaginally or concealed behind the placenta.

The nurse is caring for an infant with rubella. Which signs and symptoms should the nurse expect (Select all that apply)? a. cardiac defects b. blindness c. microcephaly d. cognitive impairment e. fetal growth restriction

a. cardiac defects c. microcephaly d. cognitive impairment e. fetal growth restriction Rationale: Signs and symptoms of rubella include spontaneous abortion, fetal growth restriction, CATARACTS, cardiac defects, deafness, microcephaly, and cognitive impairment.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding progestin injections (Depo-Provera) (Select all that apply)? a. causes temporary decrease in bone density b. causes rapid weight loss c. must remember to repeat every 12 weeks d. no protection against STDs e. may cause heavy menstrual periods

a. causes temporary decrease in bone density c. must remember to repeat every 12 weeks d. no protection against STDs Rationale: Depo-Provera causes rapid WEIGHT GAIN. An advantage of Depo-Provera is that it can cause AMENORRHEA.

The nurse is caring for an infant with kernicterus. The nurse knows that this infant could be at risk for: a. cerebral palsy b. type 1 diabetes mellitus c. multiple sclerosis d. hemophelia

a. cerebral palsy Rationale: Infants who survive kernicterus may suffer from cerebral palsy, cognitive impairment, hearing loss, or more subtle long-term neurologic and developmental problems.

The nurse is assessing a postpartum client for puerperal infection. The nurse knows that which of the following factors put the client at risk for puerperal infection (Select all that apply)? a. cesarean birth b. trauma to maternal tissues during birth c. retained placental fragments d. increased acidity of the vagina e. low socioeconomic status

a. cesarean birth b. trauma to maternal tissues during birth c. retained placental fragments e. low socioeconomic status Rationale: Factors that put the client at risk for puerperal infection include history of previous infections, cesarean birth, trauma, prolonged rupture of membranes, prolonged labor, DECREASED ACIDITY OF THE VAGINA, catheterization, excessive number of vaginal examinations, retained placental fragments, hemorrhage, poor general health, poor nutrition, poor hygiene, medical conditions such as diabetes mellitus, and low socioeconomic status.

The nurse is explaining the difference between various cardiac defects. Which of the following is considered a defect with obstruction of blood outflow? a. coarctation of the aorta b. ventricular septal defect c. Tetralogy of Fallot d. patent ductus arteriosus

a. coarctation of the aorta Rationale: Ventricular septal defect is a left-to-right shunting defect. Tetralogy of Fallot is a defect with decreased pulmonary blood flow. Patent ductus arteriosus is an acyanotic defect.

A nurse is caring for a client who is suspected of preterm labor. The nurse knows that symptoms of preterm labor include (Select all that apply): a. constant low backache b. purulent vaginal discharge c. sensation of pelvic pressure d. a general sense of malaise e. cramps similar to menstrual cramps

a. constant low backache c. sensation of pelvic pressure d. a general sense of malaise e. cramps similar to menstrual cramps Rationale: Signs and symptoms of preterm labor include constant low backache; sensation of pelvic pressure; a general sense of malaise; cramps similar to menstrual cramps with or without diarrhea; uterine contractions that may not be painful; a sensation that the baby is frequently balling up; pain, discomfort, or pressure in the vagina or thighs; and a change or increase in vaginal discharge.

The nurse is preparing an infant for a potentially painful procedure. Which of the following interventions performed by the nurse can help reduce pain in the infant (Select all that apply)? a. containment b. encourage breastfeeding c. give the infant a pacifier with sucrose if appropriate d. prepare to get the most traumatic procedures out of the way first e. talk softly to the infant

a. containment b. encourage breastfeeding c. give the infant a pacifier with sucrose if appropriate e. talk softly to the infant Rationale: Containment stimulates the enclosed space of the uterus and is comforting to infants. It involves keeping the extremities flexed with swaddling. Breastfeeding and skin-to-skin contact are often combined to increase pain relief. Sucrose placed on a pacifier 2-3 minutes before a painful stimulus increases pain relief. THE LEAST TRAUMATIC PROCEDURES SHOULD BE PERFORMED FIRST because the infant is often hypersensitive after a painful stimulus and may perceive other activities as painful. Talking softly, holding, and rocking are other common methods of pain relief.

The nurse is teaching about side effects of intrauterine devices (IUDs). Which of the following should the nurse include (Select all that apply)? a. cramping b. decreased bleeding during menstruation c. irregular bleeding after insertion d. iron deficiency anemia e. dysmenorrhea

a. cramping c. irregular bleeding after insertion d. iron deficiency anemia e. dysmenorrhea Rationale: MENORRHAGIA (INCREASED BLEEDING DURING MENSTRUATION) is a common side effect of the copper-containing ParaGard.

The nurse preceptor is assessing a newly licensed nurse's knowledge of apneic spells versus periodic breathing. The newly licensed nurse accurately relays that apneic spells involve breathing that lasts more than 20 seconds or less if accompanied by (Select all that apply): a. cyanosis b. pallor c. tachycardia d. bradycardia e. hypotonia

a. cyanosis b. pallor d. bradycardia e. hypotonia

The nurse preceptor is reviewing common signs of cardiac anomalies with a newly licensed nurse. Which signs should the nurse preceptor include (Select all that apply)? a. cyanosis increasing with crying b. apnea c. choking spells d. bradycardia e. murmurs

a. cyanosis increasing with crying c. choking spells e. murmurs Rationale: Common signs of cardiac anomalies include cyanosis increasing with crying; pallor; murmurs; TACHYCARDIA; TACHYPNEA; dyspnea; choking spells; poor intake, falling asleep during feedings; and diaphoresis.

The nurse knows that fetal indications for antepartum fetal surveillance include (Select all that apply): a. decreased fetal movement b. multiple gestation c. male gender d. amniotic fluid abnormalities e. post term

a. decreased fetal movement b. multiple gestation d. amniotic fluid abnormalities e. post term Rationale: The gender of the fetus does not determine whether antepartum fetal surveillance should be performed. Other fetal indications include growth restriction, fetal anomalies, and preterm premature rupture of membranes.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding oral contraceptives (Select all that apply)? a. decreased incidence of PMS and PMDD b. don't have to take every day c. helps with DVT d. regulates menstrual cycles e. fertility usually returns within 3 weeks

a. decreased incidence of PMS and PMDD d. regulates menstrual cycles Rationale: A disadvantage of oral contraceptives is that they must be taken AT THE SAME TIME EVERY SINGLE DAY. Oral contraceptives have an INCREASED INCIDENCE OF DVT. Fertility usually returns within 3 MONTHS.

The nurse caring for a preterm infant knows that signs of inadequate thermoregulation include (Select all that apply): a. decreased muscle tone b. yellow skin c. signs of hyperglycemia d. weak cry e. poor feeding

a. decreased muscle tone d. weak cry e. poor feeding Rationale: Signs of inadequate thermoregulation in a preterm infant include axillary temperature <97.3°F or >98.4°F; skin temperature <96.8°F or >97.7°F; poor feeding or feeding intolerance; irritability followed by lethargy; weak cry or suck; decreased muscle tone; cool skin temperature; MOTTLED, PALE, OR ACROCYANOTIC SKIN; signs of HYPOGLYCEMIA; signs of respiratory difficulty; and poor weight gain, if chronic.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding intrauterine devices (IUDs) (Select all that apply)? a. decreases dysmenorrhea and menstrual blood loss b. low long-term cost c. no serious side effects d. in place at all times e. protects against STDs

a. decreases dysmenorrhea and menstrual blood loss b. low long-term cost d. in place at all times Rationale: IUDs may have serious side effects such as ECTOPIC PREGNANCY OR PERFORATION. An IUD DOES NOT protect against STDs.

The nurse is assessing a client for signs and symptoms of postpartum depression. Which signs should indicate that this client is experiencing postpartum depression (Select all that apply)? a. depression b. feeling unwell c. less responsive to infant d. agitation e. fatigue

a. depression b. feeling unwell c. less responsive to infant d. agitation e. fatigue Rationale: Signs and symptoms of postpartum depression include depression, feeling unwell, decreased responsiveness to the infant, agitation, fatigue and lack of energy, anxiety, feelings of guilt, sleeplessness, irritability, difficulty concentrating or making decisions, confusion, appetite changes, loss of pleasure in normal activities, crying, sadness, and suicidal thoughts.

A client is scheduled for a specialized ultrasound. The nurse knows that this procedure is likely ordered to: a. detect fetal growth abnormalities b. assess amniotic fluid volume c. assess fetal presentation d. confirm the presence of a four-chamber heart

a. detect fetal growth abnormalities Rationale: A basic ultrasound is used to assess amniotic fluid volume and fetal presentation. A limited ultrasound is used to confirm the presence of a four-chamber heart. Other indications include suspected or known fetal structure anomaly; suspected or known fetal genetic or chromosomal abnormalities; history of pregnancy with anatomic, genetic, or chromosomal abnormality; and maternal-fetal complications that affect the fetus (Rh-sensitization).

The nurse is discussing retrograde ejaculation. Which conditions will the nurse include as a potential cause of retrograde ejaculation (Select all that apply)? a. diabetes b. emphysema c. neurologic disorders d. damage to the spinal cord e. osteoporosis

a. diabetes c. neurologic disorders d. damage to the spinal cord Rationale: Conditions that may cause retrograde ejaculation are diabetes, neurologic disorders, surgery that impairs function of the sympathetic nerves, and spinal cord injury.

The nurse is caring for a client who is diagnosed with an inevitable spontaneous abortion. The nurse knows that the health care provider will likely perform: a. dilation and curettage (D&C) b. dilation and evacuation (D&E) c. laparoscopy d. cerclage

a. dilation and curettage (D&C) Rationale: D&E is performed in the case of an incomplete spontaneous abortion. Laparoscopy is the examination of the peritoneal cavity in the event of a suspected ectopic pregnancy. Cerclage is the suturing of the cervix to prevent early dilation in the client with recurrent spontaneous abortion.

The nurse is providing home care teaching to the client with hyperemesis gravidarum (HEG). Which advice should the nurse include in the teaching? a. drink ginger-infused tea to reduce nausea b. lie down after meals to provide relaxation c. increase the use of iron supplements d. avoid carbohydrates as these can increase nausea

a. drink ginger-infused tea to reduce nausea Rationale: The client should sit upright after meals to reduce gastric reflux. Iron supplements may be stopped in the first trimester to assist with reduction of nausea and vomiting. Easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent low blood glucose levels, with can contribute to nausea.

The nurse is assessing a client with suspected pulmonary embolism (PE). The nurse knows to assess for which of the following manifestations (Select all that apply)? a. dyspnea b. bradycardia c. bradypnea d. pulmonary crackles e. abdominal pain

a. dyspnea d. pulmonary crackles e. abdominal pain Rationale: Signs of symptoms of a PE include dyspnea, chest pain, TACHYCARDIA, TACHYPNEA, hemoptysis, pulmonary crackles, cough, abdominal pain, low-grade fever, and decreased oxygen saturation.

The nurse assessing a pregnant teenager knows that the three most important areas of cognitive development are (Select all that apply): a. egocentrism b. information processing c. abstract thinking d. memory e. present-future orientation

a. egocentrism c. abstract thinking e. present-future orientation Rationale: Egocentrism involves the ability to defer personal satisfaction to respond to the needs of the infant. Present-future orientation involves the ability to make long-term plans. Abstract thinking involves identification of cause and effect.

The nurse is caring for a client who is in the first stage of labor and recently suffered a myocardial infarction (MI). Which intervention is appropriate at this time? a. epidural to decrease maternal oxygen consumption b. supine positioning to maintain stable cardiac output during labor c. instructing the client to bear down and push to speed up delivery and increase maternal recovery d. apply oxygen via nasal cannula

a. epidural to decrease maternal oxygen consumption Rationale: Labor management after an MI includes lateral positioning, laboring down, and antibiotic prophylaxis. Oxygen is administered via nonrebreather mask.

The nurse is providing a seminar on reducing the risk of coronary artery disease for a group of at risk women. Which health promotion activities should the nurse include (Select all that apply)? a. exercise b. limit alcohol to 2-3 drinks per day c. limit smoking to 2-3 cigarettes per day d. control high blood pressure e. control diabetes

a. exercise d. control high blood pressure e. control diabetes Rationale: Health promotion activities to reduce the risk for coronary artery disease include STOP SMOKING, maintain a normal weight, eat right, limit alcohol to 1 DRINK PER DAY, control high blood pressure, exercise, and control diabetes.

The nurse is caring for a preterm infant who is at risk for infection. Which factors put this infant at risk for infection (Select all that apply)? a. exposure to maternal infection b. lack of immunity from IgM c. immature response to infection d. prolonged hospital stays e. invasive procedures

a. exposure to maternal infection c. immature response to infection d. prolonged hospital stays e. invasive procedures Rationale: Lack of adequate passive immunity from the transfer of IMMUNOGLOBULIN G (IgG) from the mother during the third trimester could contribute to infection.

The nurse assessing for pain in an infant knows to look for the following common signs of pain (Select all that apply): a. eyes squeezed shut b. mouth squeezed shut c. decreased oxygen saturation d. weak cry e. decreased blood pressure

a. eyes squeezed shut c. decreased oxygen saturation Rationale: Common signs of pain in infants include increased or decreased heart rate and respiratory rates, apnea, INCREASED BLOOD PRESSURE; decreased oxygen saturation; color changes such as red, dusk, or pale; HIGH-PITCHED, INTENSE, HARSH CRY; whimpering, moaning; "cry face"; eyes squeezed shut; MOUTH OPEN; grimacing; furrowing or bulging of the brow; tense, rigid muscles or flaccid muscle tone; rigidity or flailing of extremities; and sleep-wake pattern changes.

The nurse is providing community teaching on maternal and fetal effects of alcohol abuse during pregnancy. Which of the following should the nurse include (Select all that apply)? a. facial and cranial anomalies b. placenta previa c. developmental delay d. induced abortion e. fetal demise

a. facial and cranial anomalies c. developmental delay e. fetal demise Rationale: Alcohol abuse can cause placental abruption and spontaneous abortion. Other effects include fetal growth restriction, fetal alcohol spectrum disorders, cognitive impairment, and short attention span.

The nurse is assessing a client with suspected postpartum psychosis. Along with the symptoms of postpartum depression, the nurse knows to look for (Select all that apply): a. failure to be able to identify reality b. confusion c. hypersomnia d. decreased activity e. hallucinations

a. failure to be able to identify reality b. confusion e. hallucinations Rationale: Symptoms of postpartum psychosis include INSOMNIA, HYPERACTIVITY, suicide, homicide, and infanticide.

The nurse suspects a client with gestational diabetes (GDM) may be developing hyperglycemia. Which symptoms may lead the nurse to come to this conclusion (Select all that apply)? a. fatigue b. pallor c. rapid, shallow respirations d. depressed reflexes e. oliguria

a. fatigue d. depressed reflexes Rationale: Signs and symptoms of maternal hyperglycemia include flushed, hot skin; rapid, deep respirations; and frequent urination. Other signs and symptoms may include dry mouth, excessive thirst, drowsiness, and headache.

A nurse is caring for a client in precipitous labor. Which of the following is priority nursing care for this client? a. fetal oxygenation b. fetal presentation c. fetal station d. fetal position

a. fetal oxygenation Rationale: Although fetal presentation, station, and position are important, they are not the priority nursing care at this time. Maternal comfort is also priority nursing care during precipitous labor.

The nurse is providing community teaching on maternal and fetal effects of antidepressants during pregnancy. Which of the following should the nurse include (Select all that apply)? a. fetal respiratory problems b. fetal euphoria c. poor tone d. persistent pulmonary hypotension e. relief of maternal anxiety and depression

a. fetal respiratory problems c. poor tone e. relief of maternal anxiety and depression Rationale: Effects include fetal irritability and persistent pulmonary hypertension. Other effects include fetal thrombocytopenia.

A client who is 3 weeks postpartum is admitted with suspected mastitis. Which clinical manifestations may lead the nurse to suspect this (Select all that apply)? a. flulike symptoms b. temperature ≥101.4°F c. wedge-shaped area of pain d. a hard, tender area d. chills

a. flulike symptoms c. wedge-shaped area of pain d. a hard, tender area d. chills Rationale: Signs and symptoms of mastitis include flulike symptoms with fatigue and aching muscles; a TEMPERATURE ≥102.2°F, chills, malaise, and headache; a localized lump or wedge-shaped area of pain, redness, heat, inflammation, and enlarged axillary lymph nodes; and a hard, tender area.

The nurse is assessing an infant with transient tachypnea of the newborn (TTN). The nurse knows that the infant will most likely display which of the following manifestations (Select all that apply)? a. grunting b. nasal flaring c. hypoinflation on chest radiography d. retractions e. mild cyanosis

a. grunting b. nasal flaring d. retractions e. mild cyanosis Rationale: Manifestations of TTN include grunting; retractions; nasal flaring; mild cyanosis; and chest radiography that demonstrates HYPERINFLATION, engorged lymphatics, and the presence of fluid in the fissures between the lobes and the pleural space.

The nurse is assessing a client with gestational diabetes (GDM) for hypoglycemia. Which symptoms should the nurse expect if the client is hypoglycemic (Select all that apply)? a. headache b. tremors c. erythema d. disorientation e. anorexia

a. headache b. tremors d. disorientation Rationale: Signs of hypoglycemia include headache, tremors, disorientation, PALLOR, HUNGER, sweating, and blurred vision.

A nurse is discussing side effects of the Depo-Provera hormonal injection. Which side effects should the nurse include (Select all that apply)? a. headache b. increased libido c. depression d. weight loss e. hair loss

a. headache c. depression e. hair loss Rationale: Side effects of Depo-Provera include WEIGHT GAIN, headaches, depression, hair loss, nervousness, DECREASED LIBIDO, and breast discomfort.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding emergency contraception (Select all that apply)? a. helps prevent pregnancy after coitus b. can be taken up to a week after intercourse c. regulates menstrual cycles d. some available without prescription e. protects against STDs

a. helps prevent pregnancy after coitus d. some available without prescription Rationale: Must be taken within 5 DAYS OF UNPROTECTED INTERCOURSE. Emergency contraception DOES NOT REGULATE MENSTRUAL CYCLES or PROTECT AGAINST STDs.

The nurse is providing education about sterilization to a couple over the age of 40. Which of the following complications should the nurse include (Select all that apply)? a. hemorrhage b. hypertension c. infection d. anesthesia complications e. ectopic pregnancy

a. hemorrhage c. infection d. anesthesia complications e. ectopic pregnancy Rationale: Pregnancies after tubal sterilization are more likely to be ectopic.

The nurse is caring for an infant with hepatitis B. What does the nurse understand about hepatitis B (Select all that apply)? a. hepatitis B can be transmitted through breast milk b. the infant is most likely large for gestational age c. the infant is at risk for liver cancer d. breastfeeding should start immediately before vaccine is administered e. the hepatitis B vaccine should be administered after 2 weeks of life

a. hepatitis B can be transmitted through breast milk c. the infant is at risk for liver cancer Rationale: Infants with with hepatitis B are usually LOW BIRTH WEIGHT and premature. Breastfeeding can start AFTER ADMINISTRATION OF THE VACCINE. The vaccine should be administered IMMEDIATELY AFTER CLEANING.

A nurse is assessing a client at risk for postpartum depression. The nurse knows that the following factors put this client at risk for developing postpartum depression (Select all that apply): a. history of sexual abuse b. patients experiencing an unexpected pregnancy c. those who smoke d. African-Americans e. those who formula feed their baby

a. history of sexual abuse b. patients experiencing an unexpected pregnancy c. those who smoke e. those who formula feed their baby Rationale: Maternal race is not a risk factor for postpartum depression. Other risk factors include first pregnancy; single status; young maternal age; depression during pregnancy or previous postpartum depression; hormonal fluctuations that follow childbirth; medical problems during pregnancy or after birth (preeclampsia, preexisting diabetes mellitus, anemia, postpartum thyroid dysfunction); personal or family history of depression, mental illness, or alcoholism; personality characteristics, such as immaturity and low self-esteem; marital dysfunction; feelings of isolation or lack of social support; fatigue, lack of sleep; financial worries; child care stress; multifetal pregnancy; and chronic stressors.

A nurse is assessing a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following findings leads the nurse to suspect magnesium sulfate toxicity (Select all that apply)? a. hypotension b. overactive deep tendon reflexes (DTRs) c. sweating d. pallor e. respiratory depression

a. hypotension c. sweating e. respiratory depression Rationale: Magnesium sulfate toxicity could cause depressed DTRs and flushing. Other signs of magnesium sulfate toxicity include chest pain, oxygen saturation less than 95% during pregnancy and less than 92% during postpartum phase, blurred vision, altered sensorium, oliguria, and cardiac arrest.

A 37-week gestational client with suspected placental abruption is being assessed for hypovolemic shock. The nurse knows to look for the following early signs and symptoms of hypovolemic shock (Select all that apply): a. increased respiratory rate b. maternal tachycardia c. urine output less than 30 mL/h d. low oxygen saturation e. restlessness, agitation, and decreased mentation

a. increased respiratory rate b. maternal tachycardia d. low oxygen saturation Rationale: Urine output less than 30 mL/h and restlessness, agitation, and decreased mentation are late signs of hypovolemic shock, not early. Other early signs include fetal tachycardia, normal or slightly decreased blood pressure, and cool pale skin and mucous membranes. Late signs include falling blood pressure and oxygen saturation levels and skin that becomes cold and clammy.

The nurse is caring for an infant with candidiasis. What does the nurse know about candidiasis (Select all that apply)? a. infants may experience white patches in mouth b. acyclovir drops should be administered c. infants may have a rash on the perineum d. candidiasis is acquired before birth e. IV medications are required for systemic infections

a. infants may experience white patches in mouth c. infants may have a rash on the perineum e. IV medications are required for systemic infections Rationale: NYSTATIN DROPS should be administered. Candidiasis is acquired DURING BIRTH.

The nurse is discussing the potential causes of an infant's hypocalcemia with a client. The nurse includes which of the following as risk factors of hypocalcemia (Select all that apply)? a. infants of diabetic mothers (IDMs) b. postterm infants c. asphyxia d. hyperthyroidism e. delayed nutrition

a. infants of diabetic mothers c. asphyxia e. delayed nutrition Rationale: Early-onset hypocalcemia occurs most often in IDMs and in infants with asphyxia, PREMATURITY, and delayed nutrition. Late-onset hypocalcemia is caused by HYPOPARATHYROIDISM, malabsorption, low magnesium levels, extensive diuretic therapy, and rickets.

A nurse is providing care for a multigravida client who had a previous preterm labor. The nurse knows that risk factors of preterm labor include (Select all that apply): a. infection or inflammation b. uteroplacental ischemia or hemorrhage c. overproduction of progesterone d. maternal stress e. chronic hypotension

a. infection or inflammation b. uteroplacental ischemia or hemorrhage d. maternal stress Rationale: An increase in progesterone would not cause a client to go into preterm labor. Preterm labor could be caused by chronic hypertension, not hypotension. Other causes include urinary tract infections, periodontal disease, connective tissue disorders, drug abuse, short cervical length, multifetal gestation, preterm membrane rupture, preeclampsia, bleeding disorders, gestational diabetes, obesity, previous preterm birth, dehydration, anemia, poor nutrition, domestic violence, and low socioeconomic status.

The nurse is providing information to a couple trying to get pregnant. The husband asks why his sperm count may be low. The nurse explains that factors that can impair the number and function of the sperm include (Select all that apply): a. infections of the genital tract b. a decreased scrotal temperature c. use of illicit drugs such as marijuana or cocaine d. exposure to toxins such as lead or pesticides e. acute or chronic illness such as cirrhosis or renal failure

a. infections of the genital tract c. use of illicit drugs such as marijuana or cocaine d. exposure to toxins such as lead or pesticides e. acute or chronic illness such as cirrhosis or renal failure Rationale: Factors that can impair the number and function of the sperm include abnormal hormonal stimulation of sperm production; anatomic abnormalities such as a varicocele or obstruction of the ducts that carry sperm to the penis; therapeutic treatments such as antineoplastic drugs or radiation for cancer; excessive alcohol intake; an ELEVATED SCROTAL TEMPERATURE resulting from febrile illness, repeated use of saunas or hot tubs, or sitting for prolonged periods; and immunologic factors, produced by the man against his own sperm or by the woman, causing the sperm to clump or be unable to penetrate the ovum.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding the cervical cap (Select all that apply)? a. initially expensive b. risk for bladder infection c. requires health care provider to fit it d. must remain in place for at least 3 hours after coitus e. provides no protection against STDs

a. initially expensive c. requires health care provider to fit it Rationale: No pressure against bladder as with diaphragm, so NO RISK OF BLADDER INFECTION. Must remain in place for AT LEAST 6 HOURS AFTER COITUS. Provides SOME protection against STDs.

A nurse is caring for a client diagnosed with preeclampsia. The nurse knows that fetal complications associated with preeclampsia include (Select all that apply): a. intrauterine growth restriction b. fetal intolerance to labor c. intrauterine fetal death d. postterm birth e. decreased oxygenation

a. intrauterine growth restriction b. fetal intolerance to labor c. intrauterine fetal death e. decreased oxygenation Rationale: Preterm birth, not postterm birth, is a fetal complication of preeclampsia. Other fetal complications include low birth weight.

A nurse is discussing side effects of the Nexplanon contraceptive implant. Which of the following should the nurse include in the teaching (Select all that apply)? a. irregular menstrual bleeding b. weight loss c. acne d. amenorrhea e. hypertension

a. irregular menstrual bleeding c. acne d. amenorrhea Rationale: Side effects of Nexplanon include irregular menstrual bleeding, WEIGHT GAIN, acne, and amenorrhea with longer use.

The nurse is assessing an infant for signs of hypocalcemia. Which signs should the nurse expect (Select all that apply)? a. irritability b. jitteriness c. tachypnea d. muscle twitching e. poor tone

a. irritability b. jitteriness d. muscle twitching Rationale: Manifestations of hypocalcemia include irritability, jitteriness, POOR FEEDING, high-pitched cry, muscle twitching, APNEA, seizures, and electrocardiographyic changes.

A nurse assessing a client in labor notes that the client appears more stressed than expected. The nurse knows that responses to excessive or prolonged stress interfere with labor in which of the following ways (Select all that apply)? a. labor contractions are less effective b. secretion of catecholamines inhibit uterine contractions c. increased glucose consumption reduces the energy supply available to the contracting uterus d. pain perception is increased and pain intolerance is decreased e. maternal pushing efforts are less effective because of the tense abdominal and pelvic muscles

a. labor contractions are less effective b. secretion of catecholamines inhibit uterine contractions c. increased glucose consumption reduces the energy supply available to the contracting uterus d. pain perception is increased and pain intolerance is decreased e. maternal pushing efforts are less effective because of the tense abdominal and pelvic muscles Rationale: Excessive or prolonged stress can cause less effective contractions; secretion of catecholamines that inhibit uterine contractions; increased glucose consumption that reduces the energy supply to the contracting uterus; increased pain perception; decreased pain tolerance; and tense abdominal and pelvic muscles that make maternal pushing efforts less effective.

The nurse is caring for an infant with hyperbilirubinemia. Which of the following manifestations indicate this infant may be developing bilirubin encephalopathy (Select all that apply)? a. lethargy b. decreased muscle tone c. hyper Moro reflex d. high-pitched cry e. poor feeding

a. lethargy b. decreased muscle tone d. high-pitched cry e. poor feeding Rationale: Clinical manifestations of bilirubin encephalopathy include lethargy, increased or decreased muscle tone, poor feeding, DECREASED OR ABSENT MORO REFLEX, high-pitched cry, opisthotonos, and seizures.

The nurse is caring for an infant with herpes. Which signs and symptoms should the nurse expect (Select all that apply)? a. lethargy b. seizures c. cyanosis d. vesicles e. temperature instability

a. lethargy b. seizures d. vesicles e. temperature instability Rationale: Signs and symptoms of herpes include clusters of vesicles, temperature instability, lethargy, poor suck, seizures, encephalitis, JAUNDICE, and purpura.

A client at risk for preterm labor is prescribed magnesium sulfate. The nurse knows that possible side effects of magnesium sulfate include (Select all that apply): a. lethargy b. hyperactive deep tendon reflexes (DTRs) c. headache d. sensation of cold e. nausea

a. lethargy c. headache e. nausea Rationale: Magnesium sulfate could cause depression of DTRs and a sensation of heat. Other side effects include respiratory and cardiac depression, weakness, visual blurring, vomiting, and constipation.

The nurse preparing to assess a postterm infant knows that this infant will likely display which physical signs of postmaturity syndrome (Select all that apply)? a. little or no vernix b. abundant hair on the head c. thick umbilical cord d. skin is wrinkled, cracked, and peeling e. excess subcutaneous fat

a. little or no vernix b. abundant hair on the head d. skin is wrinkled, cracked, and peeling Rationale: Infants with postmaturity syndrome may have an apprehensive look associated with hypoxia. The infant may be thin with loose skin and LITTLE SUBCUTANEOUS FAT. The umbilical cord is THIN with little Wharton's jelly. There is little vernix caseosa, but the infant generally has abundant hair on the head and long nails. The skin is wrinkled, cracked, and peeling.

The nurse is assessing a client with a mood disorder. The nurse knows that signs and symptoms of a mood disorder include (Select all that apply): a. loss of energy b. increased appetite c. agitation c. fatigue e. headache

a. loss of energy c. agitation c. fatigue e. headache Rationale: Signs and symptoms of a mood disorder include loss of appetite. Other signs and symptoms include anxiety, a constant sad mood, crying fits, feelings of worthlessness, and difficulty concentrating or thinking.

The nurse is assessing a client with suspected postpartum psychosis. The nurse knows that the following criteria are required for an episode to truly be characterized as postpartum psychosis (Select all that apply): a. major depressive disorder with psychotic traits b. bipolar I c. schizoaffective disorder d. generalized anxiety disorder e. unspecified functional psychosis

a. major depressive disorder with psychotic traits b. bipolar I c. schizoaffective disorder e. unspecified functional psychosis Rationale: Generalized anxiety disorder is not one of the criteria for postpartum psychosis. Other criteria include short-term psychotic disorder and bipolar II.

The nurse is assessing a large-for-gestational-age (LGA) infant. The client asks how this could have happened. The nurse explains that risk factors for LGA infants include (Select all that apply): a. maternal diabetes b. nulliparas c. mothers who are underweight d. mothers who are African American e. mothers who are Asian

a. maternal diabetes d. mothers who are African American e. mothers who are Asian Rationale: Risk factors for LGA infants include MULTIPARAS; large parents; MOTHERS WHO ARE OBESE; mothers who are Asian, African American, or Hispanic; and mothers with diabetes.

The nurse is providing community teaching on maternal and fetal effects of cocaine abuse use during pregnancy. Which of the following should the nurse include (Select all that apply)? a. maternal euphoria b. placental abruption c. fetal bradycardia d. meconium staining e. postterm labor

a. maternal euphoria b. placental abruption d. meconium staining Rationale: Effects include fetal tachycardia and preterm labor. Other effects include maternal hyperarousal state, vasoconstriction, hypertension, tachycardia, tremors, anorexia, and death; STDs; spontaneous abortion; preeclampsia; premature rupture of membranes; precipitous delivery; fetal hypoxia and irritability; stillbirth; prematurity; and sleep followed by agitation, poor response to comforting or interaction, possible attention and language problems in newborn.

A client has been in active labor for over 17 hours. The nurse knows that possible maternal and fetal problems in prolonged labor include (Select all that apply): a. maternal exhaustion b. maternal infection c. neonatal infection d. preeclampsia e. placenta previa

a. maternal exhaustion b. maternal infection c. neonatal infection Rationale: Preeclampsia is not caused by prolonged labor. Placenta previa occurs when the placenta covers the cervical os and is not affected by the length of labor.

The nurse is providing community teaching on maternal and fetal effects of amphetamine abuse during pregnancy. Which of the following should the nurse include (Select all that apply)? a. maternal malnutrition b. increased risk for macrosomia c. abnormal fetal sleep patterns d. fetal agitation e. maternal bradycardia

a. maternal malnutrition c. abnormal fetal sleep patterns d. fetal agitation Rationale: Effects include increased risk for fetal growth restriction and maternal tachycardia. Other effects include maternal vasoconstriction and hypertension; spontaneous abortion; preterm labor; placental abruption; preeclampsia; retroplacental hemorrhage; prematurity; and fetal agitation, poor feeding, vomiting, and neonatal abstinence syndrome (high-pitched cry, jitteriness, irritability, poor feeding and sucking reflexes).

The nurse is caring for an infant with persistent pulmonary hypertension of the newborn (PPHN). The nurse knows that risk factors for PPHN include (Select all that apply): a. maternal use of NSAIDs b. hypoxemia and alkalosis c. respiratory distress syndrome d. thrombocytopenia e. maternal use of SSRIs

a. maternal use of NSAIDs c. respiratory distress syndrome e. maternal use of SSRIs Rationale: Risk factors for PPHN include maternal use of NSAIDs or SSRIs, hypoxemia and ACIDOSIS, asphyxia, meconium aspiration syndrome, sepsis, POLYCYTHEMIA, diaphragmatic hernia, and respiratory distress syndrome.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding spermicide (Select all that apply)? a. may cause irritation b. requires lubrication c. may be messy d. expensive e. suppositories must melt to be effective

a. may cause irritation c. may be messy Rationale: PROVIDES LUBRICATION and INEXPENSIVE PER SINGLE USE.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding the transdermal contraceptive patch (Select all that apply)? a. may cause skin irritation b. causes irregular menstrual cycles c. less effective for women under 120 lbs d. must replace once every 3 weeks e. higher risk for clot formation

a. may cause skin irritation e. higher risk for clot formation Rationale: The patch may HELP REGULATE MENSTRUAL CYCLES. The patch is less effective for women OVER 198 LBS. Must replace ONCE A WEEK.

A client who is at 41 weeks of gestation still has not gone into labor. The nurse knows that the fetus could be at risk for (Select all that apply): a. meconium aspiration syndrome b. polyhydramnios c. cord compression d. late growth restriction e. respiratory distress

a. meconium aspiration syndrome c. cord compression d. late growth restriction e. respiratory distress Rationale: The postterm fetus is at risk for oligohydramnios, not polyhydramnios.

A nurse is caring for a client diagnosed with an ectopic pregnancy. Which of the following medications should the nurse expect the provider to prescribe? a. methotrexate b. metoprolol c. pitocin d. magnesium sulfate

a. methotrexate Rationale: Methotrexate, a chemotherapeutic agent, is a folic acid antagonist that inhibits cell replication and targets rapidly dividing cells. It is approximately 90% effective in treating ectopic tubal pregnancy.

The nurse is teaching a client about possible irreparable defects. Which of the following are examples of irreparable defects (Select all that apply)? a. microcephaly b. cleft palate c. hypospadias d. trisomy 21 e. amelia

a. microcephaly d. trisomy 21 e. amelia Rationale: Microcephaly, trisomy 21, and amelia (absence of an entire limb) are defects that cannot be fixed and will remain with the infant for life.

A client is undergoing a nonstress test (NST). The nurse knows that a reactive NST is defined as: a. more than two accelerations in a 40-minute period b. fewer than two accelerations in a 40-minute period c. recurrent variable decelerations lasting 40 seconds d. 3 or more variable decelerations in a 20-minute period

a. more than two accelerations in a 40-minute period Rationale: fewer than two accelerations in a 40-minute period are considered a nonreactive NST. Any variable decelerations can indicate cord compression and require further intervention.

The nurse is assessing an infant who develops transient tachypnea of the newborn (TTN). The parents ask if they did anything to cause this. The nurse explains that risk factors of TTN include (Select all that apply): a. multiple gestation b. lack of maternal sedation c. prolonged labor d. female gender e. vaginal birth

a. multiple gestation c. prolonged labor Rationale: Risk factors for TTN include CESAREAN BIRTH, macrosomia, multiple gestation, EXCESSIVE MATERNAL SEDATION, prolonged or precipitous labor, MALE GENDER, and maternal diabetes or asthma.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding condoms (Select all that apply)? a. must be checked for expiration dates b. requires a prescription c. interferes with spontaneity d. female condoms may seem unattractive e. expensive

a. must be checked for expiration dates c. interferes with spontaneity d. female condoms may seem unattractive Rationale: NO PRESCRIPTION REQUIRED and LOW COST PER SINGLE USE.

A nurse is caring for a client who had a confirmed complete spontaneous abortion. What is the most likely intervention at this time? a. no additional intervention is required b. administer oxytocin c. maintain the client on NPO status for 24 hours d. keep the client on strict bedrest for 24 hours

a. no additional intervention is required Rationale: Unless excessive bleeding or infection develops, no additional interventions are needed for the client with a confirmed complete spontaneous abortion.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding a progestin implant (Select all that apply)? a. no protection against STDs b. may cause rapid weight gain c. major side effect is irregular bleeding d. unsafe during lactation e. must be replaced every 3 months

a. no protection against STDs c. major side effect is irregular bleeding Rationale: BODY WEIGHT HAS NO EFFECT on the progestin implant. The progestin implant is SAFE TO USE DURING LACTATION. The progestin implant provides 3-YEAR PROTECTION.

The nurse knows that common methods of antepartum fetal surveillance include (Select all that apply): a. nonstress test (NST) b. amniocentesis c. contraction stress test (CST) d. biophysical profile (BPP) e. preimplantation genetic diagnosis

a. nonstress test (NST) c. contraction stress test (CST) d. biophysical profile (BPP) Rationale: Amniocentesis and preimplantation genetic diagnosis are both prenatal diagnostic tests. Other methods include fetal movement counting (FMC), modified biophysical profile (MBPP), and doppler flow studies.

The nurse is assessing the urinary output of a 19-hour-old preterm infant weighing 5 lbs 3 oz (5.2 lbs). The infant's urinary output for the past hour is 3.5 mL. How should the nurse document this in the infant's chart? a. normal urine output b. excessive urinary output c. diminished urinary output

a. normal urine output Rationale: Normal urinary output is 1-3 mL/kg/h for preterm infants for the first few days. First, calculate the infant's weight in kg. To determine the minimum urinary output, multiply the infant's weight in kg by 1. To determine the maximum urinary output, multiply the infant's weight in kg by 3. Since the urinary output of 3.5 mL falls between the minimum and maximum of 2.4 kg and 7.2 kg, the infant's urinary output is considered normal. Weight in kg: 5.2 lbs ÷ 2.2 = 2.4 kg Minimum: 2.4 kg x 1 mL = 2.4 mL Maximum: 2.4 kg x 3 mL = 7.2 mL

A nurse is assessing a client at risk for gestational hypertension. The nurse knows that the following factors put the client at risk for gestational hypertension (Select all that apply): a. obesity b. Asian-American descent c. age older than 35 years d. metabolic syndrome e. first pregnancy

a. obesity c. age older than 35 years d. metabolic syndrome e. first pregnancy Rationale: Clients of African-American descent are more at risk for gestational hypertension, not Asian-American. Other risk factors include history of thrombophilia, in vitro fertilization, family or personal history of preeclampsia, chronic hypertension or preexisting vascular or renal disease, antiphospholipid syndrome, systemic lupus erythematosis, and multifetal pregnancy.

A nurse caring for a postpartum client is assessing for predisposing factors of uterine atony. Which signs should the nurse look for (Select all that apply)? a. overdistention of the uterus b. oligohydramnios c. obesity d. multiparity e. prolonged labor

a. overdistention of the uterus c. obesity d. multiparity e. prolonged labor Rationale: Risk factors of uterine atony include overdistention of the uterus due to multiple gestation, a large infant, or HYDRAMNIOS; multiparity; obesity; contractions that were minimally effective, resulting in prolonged labor; contractions that were excessively vigorous, resulting in precipitous labor; and oxytocin-induced labor.

A client has a suspected deep vein thrombosis (DVT). The nurse suspects this due to which of the following signs and symptoms (Select all that apply)? a. pain in the groin b. pain in the left upper quadrant c. swelling of the leg d. increased peripheral pulses e. chills

a. pain in the groin c. swelling of the leg e. chills Rationale: Signs and symptoms of DVT include pain in the leg, groin, lower back, or RIGHT LOWER QUADRANT; swelling of the leg, erythema, heat, and tenderness over the affected area; pain on ambulation; chills; general malaise; and stiffness of the affected leg.

The nurse is caring for the client experiencing early hypovolemia. What can the nurse do to promote oxygenation of tissues? a. place the client in a lateral position with the head of the bed flat to increase cardiac return b. encourage the client to ambulate to prevent pooling of blood in extremities c. provide oxygen at 2 L/min via nasal cannula d. provide detailed explanations so the client knows exactly what is going on

a. place the client in a lateral position with the head of the bed flat to increase cardiac return Rationale: Placing the client flat in the lateral position increases circulation and oxygenation of the placenta and other vital organs. The client's activity should be limited to decrease the tissue demand for oxygen. Oxygen should be provided at 8-10 mL/min via tight, non-rebreather face mask. Explanations should be kept simple with reassurance and emotional support to reduce anxiety, which increases the metabolic demand for oxygen.

A nurse is assessing a client who experienced precipitous labor. The nurse knows that which of the following conditions may be associated with precipitous labor (Select all that apply)? a. placental abruption b. low birth weight c. infection d. postpartum hemorrhage e. high Apgar scores for the infant

a. placental abruption c. infection d. postpartum hemorrhage Rationale: Low birth weight is not associated with precipitous labor. Low Apgar scores, not high, are associated with precipitous labor.

The nurse is caring for an infant with HIV. Which signs and symptoms should the nurse expect (Select all that apply)? a. pneumonia b. constipation c. meningitis d. small liver and spleen e. symptoms apparent at 12-24 hours

a. pneumonia c. meningitis Rationale: Signs and symptoms of HIV include ENLARGED LIVER AND SPLEEN, lymphadenopathy, failure to thrive, pneumonia, persistent infections, DIARRHEA, meningitis, and septic joints. Infants are asymptomatic at birth and usually show signs at 12-24 MONTHS.

A client who is at 37 weeks of gestation is rushed into the emergency room with placental abruption and excessive bleeding. Assessment reveals that the fetus is in distress. What can the nurse do at this time? a. prepare for immediate delivery b. place the client on bed rest c. request a prescription for a tocolytic to reduce uterine activity d. request a prescription for a steroid to accelerate fetal lung maturity

a. prepare for immediate delivery Rationale: Since the client is bleeding excessively, the fetus is in distress, and the client is above 34 weeks of gestation, the most appropriate action at this time is preparation for immediate delivery.

The nurse is providing community teaching on maternal and fetal effects of marijuana use during pregnancy. Which of the following should the nurse include (Select all that apply)? a. problems in motor development b. cognitive impairment c. growth restriction d. fetal demise e. memory problems

a. problems in motor development b. cognitive impairment e. memory problems Rationale: The effects of marijuana on the fetus are unclear as more study is needed. The use of marijuana may be related to problems in motor, cognitive, and behavioral development as well as memory and problem-solving issues. It is unproven whether the fetus is at an increased risk for anomalies or mortality. Consumed in large doses, marijuana can cause maternal anxiety, tachycardia, confusion, panic, and hallucinations.

The nurse assessing a client who is 3 days postpartum for subinvolution of the uterus knows to look for which of the following clinical manifestations (Select all that apply)? a. prolonged discharge of lochia b. irregular or excessive uterine bleeding c. pelvic pain d. fundus below the umbilicus e. persistent malaise

a. prolonged discharge of lochia b. irregular or excessive uterine bleeding c. pelvic pain e. persistent malaise Rationale: Signs of subinvolution include prolonged discharge of lochia, irregular or excessive uterine bleeding, profuse hemorrhage, pelvic pain or feelings of pelvic heaviness, backache, fatigue, persistent malaise, and a fundus ABOVE the umbilicus.

A client in labor expresses concern that she is extremely anxious and does not know how to calm down. The nurse can assist the client by (Select all that apply): a. promoting physical comfort such as cleanliness b. making the lights brighter so the client can see c. identifying coping measures the client finds useful d. providing accurate information e. telling the client to relax

a. promoting physical comfort such as cleanliness c. identifying coping measures the client finds useful d. providing accurate information Rationale: Dimming the lights could decrease anxiety while increasing the brightness could increase anxiety. Telling the client to relax is a nontherapeutic response and will not decrease the client's anxiety. Other interventions include establishing a trusting relationship with the woman and her significant other, making the environment comfortable by adjusting the temperature, and implementing nonpharmacologic and pharmacologic pain management.

The nurse is teaching the mother of a drug-exposed infant how to prevent frantic crying. Which measures should the nurse include (Select all that apply)? a. provide a pacifier b. swaddle the infant with the hands c. place the infant on its back d. look for signs of stress such as yawning e. slowly rock the infant on its back

a. provide a pacifier b. swaddle the infant with the hands d. look for signs of stress such as yawning Rationale: Measures to prevent frantic crying in a drug-exposed infant include swaddling the infant with the hands brought to the midline; providing a pacifier; slowly and smoothly rocking in a vertical or horizontal motion with the infant HELD UPRIGHT; cooing softly and gently; placing the infant OVER THE SHOULDER and gently stroking the back; keeping the room fairly dark; avoiding simultaneous auditory and visual stimuli; and curtailing stimulation if the infant shows signs of stress, such as yawning, sneezing, jerky movements, or spitting up.

The nurse is providing teaching to the parents of a preterm infant about kangaroo care (KC). The nurse explains that which of the following are benefits of KC (Select all that apply)? a. provides gentle stimulation b. makes breathing easier c. enhances bonding d. promotes thermoregulation e. facilitates breastfeeding

a. provides gentle stimulation b. makes breathing easier c. enhances bonding d. promotes thermoregulation e. facilitates breastfeeding Rationale: Benefits of KC include gentle stimulation, easier breathing, bonding, thermoregulation, facilitation of breastfeeding, increased rest, stability of vital signs, weight gain, shorter length of stay, less crying, and pain relief.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding the diaphragm (Select all that apply)? a. provides some protection against STDs b. can remain in place for up to 48 hours c. easy to use d. can be inserted several hours before coitus e. no need for added spermicide

a. provides some protection against STDs d. can be inserted several hours before coitus Rationale: Can remain in place for UP TO 24 HOURS. REQUIRES EDUCATION ON PROPER USE. DIFFICULT TO INSERT OR REMOVE FOR SOME WOMEN. ADDED SPERMICIDE NECESSARY FOR REPEAT COITUS.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding spermicide (Select all that apply)? a. quick and easy b. effective for up to 6 hours c. inexpensive per single use d. provides lubrication e. no new application needed for repeated intercourse within 6 hours

a. quick and easy c. inexpensive per single use d. provides lubrication Rationale: Effective time is LESS THAN 1 HOUR. NEW APPLICATION NEEDED FOR REPEATED INTERCOURSE.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding the transdermal contraceptive patch (Select all that apply)? a. regulates menstrual cycles b. more effective for women over 198 lbs c. requires only weekly application d. decreases the risk for clots e. unrelated to coitus

a. regulates menstrual cycles c. requires only weekly application e. unrelated to coitus Rationale: The patch is less effective for women over 198 lbs. The patch creates a higher risk for clot formation.

The nurse is caring for a late preterm infant. The nurse knows that this infant is at risk for (Select all that apply): a. respiratory disorders b. hyperglycemia c. alkalosis d. infection e. feeding difficulties

a. respiratory disorders d. infection e. feeding difficulties Rationale: Late preterm infants are at risk for respiratory disorders, problems with temperature maintenance, HYPOGLYCEMIA, hyperbilirubinemia, feeding difficulties, ACIDOSIS, infection, and cognitive and behavioral problems.

The nurse is assessing an infant with persistent pulmonary hypertension of the newborn (PPHN). Which of the following manifestations will the nurse expect (Select all that apply)? a. respiratory distress b. left-to-right shunting on echocardiogram c. progressive cyanosis that becomes better with handling d. decreased PaCO2 e. decreased oxygen saturation

a. respiratory distress e. decreased oxygen saturation Rationale: Infants with PPHN develop signs within the first 12 hours after birth that include tachypnea, respiratory distress, progressive cyanosis that becomes WORSE with handling, decreased oxygen saturation and PAO2, INCREASED PaCO2, acidosis, and and echocardiogram that demonstrates RIGHT-TO-LEFT shunting through the foramen ovale and ductus arteriosus.

The nurse is assessing an infant for advanced infections. Which signs may indicate advanced infection (Select all that apply)? a. respiratory failure b. enlarged liver and spleen c. seizures d. shock e. polycythemia

a. respiratory failure b. enlarged liver and spleen c. seizures d. shock Rationale: Signs that may indicate advanced infection include jaundice, evidence of hemorrhage (petechiae, purpura, pulmonary bleeding), ANEMIA, enlarged liver and spleen, respiratory failure, shock, and seizures.

The nurse is caring for an infant with syphilis. Which signs and symptoms should the nurse expect (Select all that apply)? a. rhinitis b. pneumonitis c. pink peeling rash d. polycythemia d. jaundice

a. rhinitis b. pneumonitis c. pink peeling rash d. jaundice Rationale: Signs and symptoms of syphilis include spontaneous abortion, stillbirth, enlarged liver and spleen, jaundice, hepatitis, ANEMIA, rhinitis, pink or copper-colored peeling rash, pneumonitis, osteochondritis, and CNS involvement.

The nurse is assessing the preterm infant's readiness for nipple feeding. The nurse knows this infant can start nipple feeding due to which of the following signs (Select all that apply): a. rooting b. respiratory rate above 60 breaths per minute c. the infant does not gag when the nurse places a finger in its mouth d. the infant sucks on the gavage tube e. the infant has an increasing ability to tolerate handling

a. rooting d. the infant sucks on the gavage tube e. the infant has an increasing ability to tolerate handling Rationale: Signs that nipple feeding may soon be possible include rooting; RESPIRATORY RATE BELOW 60 BREATHS PER MINUTE; increasing ability to tolerate holding and handling; sucking on the gavage tube, a finger, or a pacifier (these signs alone are not enough to indicate readiness); and THE INFANT GAGS WHEN THE NURSE PLACES A FINGER IN ITS MOUTH.

The nurse is providing home care to a client and her partner who recently suffered a perinatal loss. Which subtle cues should the nurse look for that might indicate grief (Select all that apply)? a. sighing b. excessive wakefulness c. increased appetite d. apathy e. poor hygiene

a. sighing d. apathy e. poor hygiene Rationale: Subtle cues of grief include excessive sleeping and loss of appetite. The nurse should also assess for signs of postpartum depression, PTSD, and panic disorder.

The nurse is assessing a client who is 48 hours postpartum. The nurse knows that the most common causes of late postpartum hemorrhage is (Select all that apply): a. subinvolution b. retained placental fragments c. decreased temperature d. dehydration e. infection

a. subinvolution b. retained placental fragments e. infection Rationale: The most common causes of late postpartum hemorrhage include subinvolution, retained placental fragments, and infection.

A nurse is caring for a client with suspected superficial venous thrombosis (SVT). The nurse knows to look for the following manifestations (Select all that apply): a. swelling b. pallor c. tenderness d. warmth e. claudication

a. swelling c. tenderness d. warmth e. claudication Rationale: Signs and symptoms of SVT include swelling of the involved extremity, REDNESS, tenderness, warmth, and claudication.

The nurse is caring for a client with a psychosis-associated mood disorder. The nurse knows that symptoms of a psychosis-associated mood disorder include (Select all that apply): a. symptoms of delusions b. auditory hallucinations c. failure to distinguish illusions from reality d. poor hygiene e. anger

a. symptoms of delusions b. auditory hallucinations c. failure to distinguish illusions from reality d. poor hygiene e. anger Rationale: Other signs of psychosis-associated mood disorders include cognitive impairment and disorganized thinking.

The nurse is assessing the infant for respiratory distress syndrome (RDS). Which of the following signs and symptoms should the nurse look for (Select all that apply)? a. tachypnea b. bradycardia c. nasal flaring d. erythema e. retractions

a. tachypnea c. nasal flaring e. retractions Rationale: Signs of RDS include tachypnea, TACHYCARDIA, nasal flaring, CYANOSIS, retractions of accessory muscles, and audible grunting on expiration.

The nurse is caring for an infant with chlamydia. What does the nurse know about chlamydia (Select all that apply)? a. the infant may develop conjunctivitis b. the infant may develop otitis externa c. the infant may develop pneumonia 1-2 weeks after birth d. topical treatment of conjunctivitis is not effective e. oral acyclovir is the treatment of choice

a. the infant may develop conjunctivitis d. topical treatment of conjunctivitis is not effective Rationale: The infant may develop OTITIS MEDIA. The infant may develop pneumonia 4-11 WEEKS AFTER BIRTH and conjunctivitis 1-2 WEEKS AFTER BIRTH. The oral treatment of choice is AZITHROMYCIN OR ERYTHROMYCIN.

The nurse is caring for an infant with GBS. What does the nurse know about GBS (Select all that apply)? a. the infant may experience a sudden onset of respiratory distress b. an IV antiviral should be given to the infant c. always has an early onset d. the infant may experience shock e. the infant may develop meningitis

a. the infant may experience a sudden onset of respiratory distress d. the infant may experience shock e. the infant may develop meningitis Rationale: An IV ANTIBIOTIC should be given. GBS MAY HAVE AN EARLY OR LATE ONSET.

The nurse is caring for an infant with varicella-zoster. What does the nurse know about varicella-zoster (Select all that apply)? a. the infant will develop a rash b. the infant will develop skin scarring c. varicella-zoster can cause death d. the highest incidence is between weeks 22 and 28 of gestation e. ciprofloxacin is the drug of choice

a. the infant will develop a rash b. the infant will develop skin scarring c. varicella-zoster can cause death Rationale: The highest incidence is between 13 AND 20 WEEKS OF GESTATION. ACYCLOVIR IS THE DRUG OF CHOICE.

A newly licensed nurse is caring for a client who is scheduled for a second-trimester ultrasonography. Which actions by the newly licensed nurse require the preceptor to intervene (Select all that apply)? a. the newly licensed nurse places the client in a lithotomy position b. the newly licensed nurse places the client on her back with head and knees supported c. the newly licensed nurse explains that a transvaginal probe will be inserted into the client's vagina d. the newly licensed nurse explains that a transabdominal probe will be placed on the client's abdomen e. the newly licensed nurse explains that the procedure takes 10-30 minutes

a. the newly licensed nurse places the client in a lithotomy position c. the newly licensed nurse explains that a transvaginal probe will be inserted into the client's vagina Rationale: The client should be placed on her back with her head and knees supported, a transabdominal probe is used, and the procedure lasts 10-30 minutes.

The nurse is assessing an infant who is suspected of polycythemia. Which manifestations would lead the nurse to suspect this (Select all that apply)? a. tremors b. increased bowel sounds c. respiratory distress d. cyanosis e. hyperglycemia

a. tremors c. respiratory distress Rationale: Clinical manifestations of polycythemia include PLETHORIC COLOR, lethargy, irritability, poor tone, tremors, abdominal distention, DECREASED BOWEL SOUNDS, poor feeding, HYPOGLYCEMIA, respiratory distress, and hyperbilirubinemia.

A client who received a second-trimester multiple-marker screening has low levels of alpha-fetoprotein (AFP). The nurse knows that this could suggest (Select all that apply): a. trisomy 21 b. undiagnosed multiple gestation c. a normal fetus with overestimation of gestational age d. a normal fetus with underestimation of gestational age e. abdominal wall defects

a. trisomy 21 c. a normal fetus with overestimation of gestational age Rationale: Undiagnosed multiple gestation, underestimation of gestational age, and abdominal wall defects are associated with elevated levels of AFP.

The nurse is assessing a client with diabetes. The nurse knows that the client may be at risk for the following complications (Select all that apply): a. urinary tract infections b. hypotension c. ketoacidosis d. labor dystocia e. birth injury to maternal tissues

a. urinary tract infections c. ketoacidosis d. labor dystocia e. birth injury to maternal tissues Rationale: The client with diabetes is at risk for hypertension, not hypotension.

The nurse is assessing for overhydration in the preterm infant. The nurse knows to look for which of the following signs and symptoms of overhydration (Select all that apply)? a. urine output >3 mL/kg/h b. sunken fontanels c. poor skin turgor d. weight gain greater than expected e. moist breath sounds

a. urine output >3 mL/kg/h d. weight gain greater than expected e. moist breath sounds Rationale: Signs of overhydration In the preterm infant include urine output >3 mL/kg/h; urine specific gravity <1.005; EDEMA; weight gain greater than expected; BULGING FONTANELS; decreased sodium, protein, and hematocrit levels; moist breath sounds; and difficulty breathing.

The nurse assessing the client for early postpartum hemorrhage knows that some of the causes include (Select all that apply): a. uterine atony b. hematomas c. uterine hypertony d. empty bladder e. retained placental fragments

a. uterine atony b. hematomas e. retained placental fragments Rationale: Early postpartum hemorrhage is most often caused by uterine atony. Other causes include trauma to the birth canal during labor and birth, hematomas, retention of placental fragments, abnormalities of coagulation, abnormal adherence of the placenta to the uterine wall (placenta accretia), and inversion of the uterus.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding sterilization (Select all that apply)? a. vasectomy requires another contraceptive method until semen is free of sperm b. high-cost c. reversal is difficult and expensive and may not be successful d. requires general anesthesia e. must wait 6 months after childbirth

a. vasectomy requires another contraceptive method until semen is free of sperm c. reversal is difficult and expensive and may not be successful Rationale: Sterilization has a LOW LONG-TERM COST. Tubal sterilization can be performed DURING OR RIGHT AFTER CHILDBIRTH. Vasectomy can be performed under LOCAL ANESTHESIA.

The nurse is providing care for a postpartum client with a superficial venous thrombosis (SVT). Which intervention may the nurse use to relieve the pain? a. warm packs b. cold packs c. early ambulation d. keeping the extremity below the heart

a. warm packs Rationale: To reduce the pain of an SVT, warm packs may be applied to the area, analgesics administered, and elastic support applied to improve venous return. The extremity should be ELEVATED to improve venous return. After a period of rest with the leg elevated, the woman may ambulate gradually, but should avoid standing for long periods of time.

The nurse is assessing a client suspected of heroin withdrawal. The nurse knows to look for the following symptoms (Select all that apply): a. yawning b. dry skin c. nausea d. dry eyes e. abdominal cramping

a. yawning c. nausea e. abdominal cramping Rationale: Signs of heroin withdrawal include diaphoresis and excessive tearing of the eyes. Other signs include rhinorrhea, restlessness, and vomiting.

The nurse is assessing a preterm infant and suspects that the infant is becoming overstimulated. Which signs might lead the nurse to suspect this (Select all that apply)? a. yawning b. tightly flexed arms and legs c. sneezing d. turning away from eye contact e. arching

a. yawning c. sneezing d. turning away from eye contact e. arching Rationale: Signs of overstimulation in preterm infants include blood pressure, pulse, and respiratory instability; cyanosis, pallor, or mottling; flaring nares; decreased oxygen saturation levels; apnea; sneezing, coughing; STIFF, EXTENDED ARMS AND LEGS; fisting of hands or splaying of fingers; arching; alert, worried expression; turning away from eye contact; regurgitation, gagging, hiccuping; yawning; and fatigue signs.

A nurse educator is teaching a group of nursing students about chorionic villus sampling (CVS). Which statements by a student indicates that the teaching was effective (Select all that apply) ? a. "CVS is normally performed between 20 and 25 weeks of gestation." b. "CVS is normally performed between 10 and 13 weeks of gestation." c. "CVS is used to screen for fetal chromosomal, metabolic, or DNA abnormalities." d. "CVS is used to diagnose fetal chromosomal, metabolic, or DNA abnormalities." e. "Placental tissue for a CVS can be aspirated using a transcervical, transvaginal, or trasabdominal approach."

b. "CVS is normally performed between 10 and 13 weeks of gestation." d. "CVS is used to diagnose fetal chromosomal, metabolic, or DNA abnormalities." Rationale: CVS must be performed before 20 weeks of gestation in case parents wish to terminate the fetus. CVS is a diagnostic tool and is only used if abnormalities are suspected. Placental tissue is aspirated using transcervical and transabdominal approaches. A transvaginal approach is not indicated.

A client has just had an amniocentesis performed. The nurse knows that the teaching has been effective when the client states: a. "I have a higher chance of an emergency cesarean." b. "I may experience vaginal spotting." c. "I should avoid submerging myself in a bath for the next 2 weeks." d. "I have a higher chance of going into preterm labor."

b. "I may experience vaginal spotting." Rationale: There is nothing that suggests that a client who has undergone an amniocentesis has a higher risk of emergency cesarean or preterm labor. The client does not need to avoid baths as there is a very low risk of maternal infection.

A nurse is providing teaching to a client who has just had a vasectomy. Which statement by the client indicates an understanding of the teaching? a. "I should apply ice to the area for 2 hours and take a mild analgesic." b. "I should avoid bathing for 24 hours." c. "I will wear a scrotal support for 24 hours." d. "I should avoid strenuous activity for 48 hours."

b. "I should avoid bathing for 24 hours." Rationale: The client should apply ice to the area for 4 HOURS and take a mild analgesic. The client should wear a scrotal support for 48 HOURS. The client should avoid strenuous activity for 1 WEEK.

The nurse is providing teaching to a client who is scheduled to have a high-sensitivity fecal occult blood test. Which statement by the client indicates a need for further teaching? a. "I should avoid red meat for 72 hours before testing." b. "I should collect a specimen from 5 consecutive stools." c. "I should avoid NSAIDs for at least 7 days before collecting the specimen." d. "I should return the slides within 4-6 days after the specimens are collected."

b. "I should collect a specimen from 5 consecutive stools." Rationale: The client should collect a specimen from 3 CONSECUTIVE STOOLS.

A nurse is providing discharge teaching to a client who underwent a contraction stress test (CST) received a negative result. Which statement by the client indicates that the teaching was effective? a. "This means that my baby his a higher chance of being stillborn." b. "I will need to return In 1 week to have the test performed again." c. "I do not need to have this test performed again as this is an ideal result." d. "I should have this test repeated every 24 hours until my baby is born."

b. "I will need to return In 1 week to have the test performed again." Rationale: This is an ideal result and does not suggest a higher risk of stillbirth. Even though this is an ideal result, it is still a good idea for the client to return in one week to ensure that the fetus remains viable. There is no need to repeat the test every 24 hours as the client could be several weeks away from her delivery date.

Which statement by the client indicates that she understands breast self-examination? a. "I will examine both breasts in two different positions." b. "I will perform a breast self-examination 1 week after my menstrual period starts." c. "I will examine the outer upper area of the breast only." d. "I will use the palm of the hand to perform the examination."

b. "I will perform a breast self-examination 1 week after my menstrual period starts." Rationale: The woman should examine her breasts when hormonal influences are at a low level. She should use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down. The entire breast needs to be examined, including the outer upper area. She should use the sensitive pads of the middle three fingers.

The nurse is providing teaching about hypoglycemia to a client with gestational diabetes (GDM). The nurse knows the teaching has been effective when the client states: a. "If I am hypoglycemic, I should wait 30 minutes to see if the hypoglycemia resolves on its own. b. "If I am hypoglycemic, I should immediately take 15 g of carbohydrates." c. "Hypoglycemia is better than hyperglycemia, so I should not do anything if I am hypoglycemic." d. "If I am hypoglycemic, I should immediately take 30 g of carbohydrates."

b. "If I am hypoglycemic, I should immediately take 15 g of carbohydrates." Rationale: The client should immediately take 15 g of carbohydrate if she can swallow food.

A nurse is providing teaching to a client about at-home fetal movement counting to evaluate fetal wellbeing. Which statement by the client indicates that the teaching was effective? a. "If I count 5 or more kicks or movements within a 2-hour period, my fetus is considered nonhypoxic." b. "If I count 10 or more kicks or movements within a 2-hour period, my fetus is considered nonhypoxic." c. "Fetal movement generally peaks between 9 am and 1 pm, so I should plan to count during that time." d. "If I count 10 or more kicks or movements within a 2-hour period, my fetus is considered hypoxic."

b. "If I count 10 or more kicks or movements within a 2-hour period, my fetus is considered nonhypoxic." Rationale: Any number of kicks less than 10 is considered hypoxic and should be reported. Fetal movement peaks between 9 pm and 1 am.

A client in the second stage of labor expresses her concern about pushing because she feels a tearing sensation in her perineum. What is the nurse's best response? a. "This is a sign of hemorrhage and you should stop pushing immediately." b. "This is a normal sensation, but your tissues can expand to accommodate your baby." c. "You should just push and ignore the pain." d. "This is a psychologic response as you are not ready to 'let go' of your baby."

b. "This is a normal sensation, but your tissues can expand to accommodate your baby." Rationale: Many women feel a tearing and/or burning sensation during the second stage of labor, but this is a normal sign and the client should be reassured that her labor is going smoothly.

A client who recently delivered her second child expresses concern that her 6-year-old daughter has started sucking her thumb and wetting the bed. The nurse's best response is: a. "This is abnormal and you should take your daughter to the doctor." b. "This is normal and indicates jealousy and the need for attention." c. "This is normal and indicates jealousy and the need for discipline." d. "This is abnormal but if you ignore the behavior, it should resolve on its own."

b. "This is normal and indicates jealousy and the need for attention." Rationale: Many younger children become jealous of the attention and care the infant requires. These children may regress to infantile behaviors such as bedwetting and thumb sucking. Parents should be reminded that this indicates a need for attention.

A client who underwent a chorionic villus sampling (CVS) 24 hours ago calls the triage nurse with complaints of red spotting. What is the nurse's best response? a. "This is abnormal and you should seek emergency medical care immediately." b. "This is normal and should resolve within the next day and transition to brown."

b. "This is normal and should resolve within the next day and transition to brown." Rationale: Spotting is normal and should resolve on its own.

A client had a biophysical profile performed and the score was a 3. The client asks the nurse what this score means. The nurse's best response is: a. "This is a good score and means that your baby has normal oxygenation." b. "This is not an ideal score and means that your baby could have a higher risk of stillbirth." c. "This is not an ideal score but as long as there is enough amniotic fluid, your baby's oxygenation is fine." d. "This could just indicate that your baby is asleep."

b. "This is not an ideal score and means that your baby could have a higher risk of stillbirth." Rationale: A score of 8-10 correlates with normal fetal oxygenation. A score of 4 or less is associated with perinatal asphyxia, which could lead to poor perinatal and neonatal outcomes including stillbirth. A score of 6 is equivocal if there is normal fluid. The fetus does not need to be awake to receive an accurate score.

An Rh-negative client who underwent a chorionic villus sampling (CVS) is given RhoGAM after her procedure. She asks the nurse why she is given this. The nurse's best response is: a. "This is to prevent an immune system response in case your baby is also Rh-negative." b. "This is to prevent an immune system response in case your baby is Rh-positive." c. "This is given to all mothers regardless of their blood type." d. "This should not have been given to you."

b. "This is to prevent an immune system response in case your baby is Rh-positive." Rationale: All Rh-negative mothers receive Rho-GAM in case their baby is Rh-positive to avoid fetal risks for hemolytic diseases.

A nurse educator is teaching a group of nursing students about indications for second-trimester and third-trimester ultrasonography. The nurse educator realizes that the teaching has been successful when a student says (Select all that apply): a. "This procedure is used to confirm pregnancy." b. "This procedure is used to confirm fetal viability." c. "This procedure is used to evaluate the quantity of fluid." d. "This procedure is used to determine fetal presentation." e. "This procedure is used to determine gestational age."

b. "This procedure is used to confirm fetal viability." c. "This procedure is used to evaluate the quantity of fluid." d. "This procedure is used to determine fetal presentation." e. "This procedure is used to determine gestational age." Rationale: A first-trimester ultrasonography is used to confirm pregnancy. Other indications include assessing serial fetal growth, comparing fetal growth and amniotic fluid volumes in multifetal gestations, evaluating 4 or 5 markers in a biophysical profile, and locating the placenta when placenta previa is suspected.

A nurse is providing teaching to a client who will undergo a second-trimester multiple-marker screening. Which statement by the client indicates a need for further teaching? a. "This test will screen for open neural tube defects." b. "This test will confirm open neural tube defects." c. "This test will determine the gender of my baby." d. "This test will determine the blood type of my baby."

b. "This test will confirm open neural tube defects." Rationale: A second-trimester multiple-marker screening is not a diagnostic test and is not a 100% confirmation of any abnormality. This test does not confirm the gender or blood type of the baby.

A client is scheduled for a percutaneous umbilical blood sampling (PUBS) and asks the nurse why she needs this procedure. The nurse's best response is: a. "This test will determine your baby's gender." b. "This test will detect chromosomal abnormalities." c. "This test will determine the fetal lung status." d. "This test ensures your baby can handle a vaginal birth."

b. "This test will detect chromosomal abnormalities." Rationale: A PUBS is indicated to detect chromosomal abnormalities, manage fetal hemolytic disease, and confirm congenital infection.

A client received a first-trimester screening and asks what the screening will tell her. The nurse's best response is: a. "This test will confirm trisomy 21." b. "This test will screen for trisomy 21 but a diagnostic test is required to confirm this." c. "This test is 100% accurate in diagnosing congenital heart defects." d. "This test will screen for spina bifida."

b. "This test will screen for trisomy 21 but a diagnostic test is required to confirm this." Rationale: The first-trimester screening is not a diagnostic test and is not a 100% confirmation of any abnormality. A second-trimester multiple-marker screening is used to screen for neural tube defects, such as spina bifida.

A nurse is providing teaching about biophysical profiles to a client. Which statement by the client indicates a need for further teaching? a. "This is a reflection of the central nervous system." b. "This will tell me if my baby will be diabetic." c. "This will evaluate my baby's oxygenation." d. "This can give me long-term and short-term indications of my baby's well-being."

b. "This will tell me if my baby will be diabetic." Rationale: The biophysical profile measures fetal movement, fetal tone, fetal breathing movement, and amniotic fluid amount. It does not have the capability to predict if a fetus will be diabetic.

A 32-year-old client has been diagnosed with recurrent spontaneous abortion. The client asks the nurse why she keeps having these spontaneous abortions. The nurse's best response is: a. "You've likely waited too long to have children." b. "Your reproductive tract might have a genetic abnormality." c. "Maybe you weren't meant to have children." d. "It's purely psychological."

b. "Your reproductive tract might have a genetic abnormality." Rationale: Recurrent spontaneous abortion may be caused by anomalies of the reproductive tract, such as bicornate uterus (uterus with two horns) or incompetent uterus; inadequate progesterone; systemic lupus erythematosus; diabetes mellitus; reproductive infections; and sexually transmitted diseases.

A client diagnosed with Triple I presents with a fever of 102.5°F. The nurse knows to assess the client's pulse, respirations, and blood pressure every: a. 30 minutes b. 1 hour c. 2 hours d. 3 hours

b. 1 hour Rationale: If the maternal pulse is elevated, the nurse should assess her pulse, respirations, and blood pressure hourly.

A client in labor is complaining of discomfort and the nurse notes that her bladder is distended. The nurse knows that the client should be encouraged to void every: a. 30-60 minutes b. 1-2 hours c. 2-3 hours d. 3-4 hours

b. 1-2 hours Rationale: The client should be regularly assessed for bladder distention and encouraged to void every 1-2 hours.

The nurse is assessing the urine specific gravity of a preterm infant. The nurse knows that the specific gravity should be: a. 1.001-1.010 b. 1.005-1.012 c. 1.010-1.020 d. 1.010-1.030

b. 1.005-1.012 Rationale: Normal urine specific gravity of preterm infants is 1.005-1.012. Normal urine specific gravity of adults is 1.010-1.030.

The nurse is assessing an infant with intraventricular hemorrhage (IVH). The hemorrhage has extended into the lateral ventricles without distention. The nurse knows that this IVH is considered a grade: a. 1 b. 2 c. 3 d. 4

b. 2 Rationale: Grade 1 is a very small bleed at the germinal matrix. Grade 2 extends into the lateral ventricles without distention. Grade 3 causes distention of the ventricles. Grade 4 causes ventricular dilation and extends into the surrounding brain tissue.

A client in labor is diagnosed with Triple I. The nurse knows to assess the client's temperature every: a. 1-2 hours b. 2-4 hours c. 5-7 hours d. 8-10 hours

b. 2-4 hours Rationale: The nurse should assess the client's temperature every 2-4 hours in normal labor and every 2 hours after the membranes have ruptured.

A nurse is providing teaching to a client who has experienced 2 spontaneous abortions. The nurse explains that recurrent spontaneous abortion is usually defined as: a. 2 or more spontaneous abortions b. 3 or more spontaneous abortions c. 4 or more spontaneous abortions d. 5 or more spontaneous abortions

b. 3 or more spontaneous abortions

The nurse caring for a late preterm infant knows to check the infant's temperature every _____ for the first 24 hours a. 1-2 hours b. 3-4 hours c. 5-6 hours d. 7-8 hours

b. 3-4 hours Rationale: Normal newborns usually have their temperature checked only once every 8-12 hours, but a late preterm infant may develop cold stress that is not noticed until signs appear.

The nurse is teaching a client about delayed pregnancy and advanced maternal age. The nurse explains that a woman's fertility begins to decline at: a. 30 years of age b. 32 years of age c. 35 years of age d. 37 years of age

b. 32 years of age Rationale: The woman's fertility begins to decline at 32 years of age, with the most significant decrease taking place at around 37 years of age.

The nurse assessing a client in the postpartum period with diabetes knows to assess the client's blood glucose levels at least: a. 3 times a day b. 4 times a day c. 5 times a day d. 6 times a day

b. 4 times a day Rationale: During the postpartum period, blood glucose levels should be monitored at least 4 times daily so that the insulin dose can be adjusted to meet individual needs.

The nurse is preparing to administer a loading dose of IV magnesium sulfate to a client at risk for preterm labor. What is the standard dose to infuse over 30 minutes? a. 2-4 g b. 4-6 g c. 6-8 g d. 8-10 g

b. 4-6 g Rationale: The standard loading dose of IV magnesium sulfate is 4-6 g over 30 minutes.

The nurse knows that a client in labor is experiencing tachysystole when she has more than ___ contractions in ___ minutes. a. 2; 10 b. 5; 10 c. 10; 15 d. 15; 10

b. 5; 10 Rationale: Tachysystole is defined as excessive uterine labor consisting of more than 5 contractions in 10 minutes, averaged over 30 minutes.

Fran delivered a 9 lb, 10 oz baby 1 hour ago. When the nurse arrives to perform her 15-minute assessment, she tells the nurse that she "feels all wet underneath." The nurse discover that both pads are completely saturated and that she is lying in a 6-inch diameter puddle of blood. What is the nurse's first action? a. Call for help b. Assess the fundus for firmness c. Take her blood pressure d. Check the perineum for lacerations

b. Assess the fundus for firmness Rationale: Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. The first action should be to assess the fundus. Assessing blood pressure is an important assessment with a bleeding client, but the top priority is to control the bleeding. This is done by first assessing the fundus for firmness. If bleeding continues in the presence of a firm fundus, lacerations may be the cause.

The nurse is teaching about intrauterine devices (IUDs) and explains that the longest lasting IUD at 10 years is: a. Mirena b. ParaGard c. Skyla d. Liletta

b. ParaGard Rationale: ParaGard, a copper IUD is effective immediately and can stay in place for up to 10 years.

The nurse is explaining the difference between various cardiac defects. Which of the following is considered a defect with decreased pulmonary blood flow? a. transposition of the great vessels b. Tetralogy of Fallot c. pulmonary stenosis d. patent foramen ovale

b. Tetralogy of Fallot Rationale: Transposition of the great vessels is a cyanotic defect. Pulmonary stenosis is a defect with obstruction of blood outflow. Patent foramen ovale is a left-to-right shunting defect

The client overhears the health care provider telling the nurse that her infant is at risk for kernicterus. The client asks the nurse what this means. The nurse explains that kernicterus is: a. a skin condition in which keratin deposits cause overgrowth of skin b. a type of bilirubin toxicity in which bilirubin stains the brain c. a form of retinopathy in which blindness may occur d. a condition in which the teeth are permanently stained yellow

b. a type of bilirubin toxicity in which bilirubin stains the brain Rationale: Bilirubin encephalopathy is the acute manifestation of bilirubin toxicity. This may lead to kernicterus, the chronic and permanent result of bilirubin toxicity. In this condition, bilirubin deposits cause yellowish staining of the brain, especially of the basal ganglia, cerebellum, brainstem, and hippocampus.

A client in labor is suspected of having uterine rupture. The nurse knows to look for the following manifestations (Select all that apply): a. increased uterine contractions b. abdominal pain and tenderness c. hypertension d. chest or shoulder pain e. absent fetal heart sounds

b. abdominal pain and tenderness d. chest or shoulder pain e. absent fetal heart sounds Rationale: Uterine rupture could cause cessation of uterine contractions, not an increase. Late signs of shock may occur, such as a fall in blood pressure, not hypertension. Other manifestations include tachycardia, tachypnea, pallor, cool and clammy skin, anxiety, late decelerations, reduced variability, fetal tachycardia, fetal bradycardia, absent fetal activity by ultrasound examination, and/or palpation of the fetus outside the uterus.

A client in labor is experiencing labor dystocia. The nurse knows that the client is most likely in what stage/phase of labor? a. latent phase of stage 1 b. active phase of stage 1 c. transition phase of stage 1 d. stage 2

b. active phase of stage 1 Rationale: Labor dystocia occurs during the active phase of labor, when progress normally quickens.

The nurse is discussing ovulation with a client who wants to become pregnant. The nurse explains that ovulation may be disrupted by: a. altered secretion of estrogen b. altered secretion of GnRH, FSH, and LH c. altered secretion of progesterone d. altered secretion of aldosterone

b. altered secretion of GnRH, FSH, and LH Rationale: A dysfunction of the hypothalamus or pituitary gland may alter the secretion of GnRH, FSH, and LH. Another factor includes failure of the ovaries to respond to FSH and LH stimulation, preventing maturation and release of the ovum.

The nurse is providing teaching to a client about drugs that may reduce his erections or shorten their duration. Which drugs should the nurse include (Select all that apply)? a. antibiotics b. antihypertensives c. benzodiazepines d. NSAIDs e. antidepressants

b. antihypertensives e. antidepressants

The nurse is caring for a client with diabetes. The nurse knows that infant of a diabetic mother (IDM) is at risk for which of the following complications (Select all that apply)? a. hypercalcemia b. asphyxia c. macrosomia d. anemia e. shoulder dystocia

b. asphyxia c. macrosomia e. shoulder dystocia Rationale: Complications in IDMs include higher neonatal mortality, congenital anomalies, and neural tube anomalies; cardiomegaly; macrosomia, hypoglycemia; HYPOCALCEMIA; fetal growth restriction; asphyxia; respiratory distress syndrome; and POLYCYTHEMIA.

A nurse is assessing a client who is receiving a maintenance dose of magnesium sulfate for risk of preterm labor. The nurse knows to assess for which of the following (Select all that apply)? a. urine output of at least 60 mL/h b. at least 12 breaths per minute c. oxygen saturation d. fluid overload e. presence of deep tendon reflexes

b. at least 12 breaths per minute c. oxygen saturation d. fluid overload e. presence of deep tendon reflexes Rationale: Urine output should be at least 30 mL/h.

How often should the nurse assess the level of jaundice in an infant with hyperbilirubinemia? a. at least every 4 hours b. at least every 8 hours c. at least every 12 hours d. at least every 24 hours

b. at least every 8 hours Rationale: Assess the level of jaundice at least every 8 hours by blanching the skin to see the color in the area before blood returns.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding the diaphragm (Select all that apply)? a. must remain in place at least 8 hours after coitus b. bladder infection may occur c. women who gain or lose 5 pounds must be refitted d. possibility of toxic shock syndrome with prolonged use e. requires education on proper use

b. bladder infection may occur d. possibility of toxic shock syndrome with prolonged use e. requires education on proper use Rationale: Must remain in place at least 6 HOURS AFTER COITUS. Women who gain or lose 10 POUNDS must be refitted.

The nurse caring for an infant suspects a diaphragmatic hernia. Which of the following manifestations would lead to this conclusion? a. abdominal distention b. bowel sounds heard in the chest c. crackles over the affected areas d. heartbeat displaced to the left

b. bowel sounds heard in the chest Rationale: An infant with a diaphragmatic hernia may display respiratory distress at birth, with breath sounds diminished or absent over the affected area, and barrel chest; the heartbeat may be displaced to the RIGHT; bowel sounds are heard in the chest; and the abdomen may be SCAPHOID (CONCAVE).

Which of the following are potential neonate complications of oxygen therapy (Select all that apply)? a. respiratory alkalosis b. bronchopulmonary dysphasia c. retinopathy of prematurity d. long-term oxygen dependence e. intraventricular hemorrhage

b. bronchopulmonary dysphasia c. retinopathy of prematurity e. intraventricular hemorrhage Rationale: Bronchopulmonary dysphasia is a permanent lung disease that results from barotrauma caused by oxygen constantly hitting the alveoli. These infants have a higher risk of asthma. Retinopathy of prematurity occurs when arteries behind the retina rupture due to oxygen therapy. Intraventricular hemorrhage occurs when the ventricles in the head are not mature enough and rupture due to oxygen therapy. These infants may develop learning disabilities.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding the sponge (Select all that apply)? a. protects against STDs b. can be inserted several hours before coitus c. can remain in place for up to 48 hours d. effective for repeated intercourse e. no prescription needed

b. can be inserted several hours before coitus d. effective for repeated intercourse e. no prescription needed Rationale: NO PROTECTION AGAINST STDs. Risk for toxic shock syndrome if USED TOO LONG. Must not remain in place for more than 30 HOURS TOTAL.

A nurse is assessing a client who is 31 weeks of gestation and going into preterm labor. The nurse knows that the newborn could be at risk for (Select all that apply): a. spina bifida b. cerebral palsy c. trisomy 21 d. developmental delay e. vision and hearing impairment

b. cerebral palsy d. developmental delay e. vision and hearing impairment Rationale: Spina bifida and trisomy 21 are a neural tube defect and chromosomal abnormality, respectively, and are not related to preterm labor.

A nurse is assessing a client who is at 11 weeks of gestation. The nurse suspects an inevitable spontaneous abortion. Which finding might have led the nurse to this conclusion? a. vaginal bleeding b. cervical dilation c. uterine cramping d. nausea

b. cervical dilation Rationale: Neither vaginal bleeding, uterine cramping, nor nausea should lead the nurse to suspect an inevitable spontaneous abortion. Rupture of membranes may also indicate an inevitable spontaneous abortion.

The nurse is assessing a small-for-gestational-age (SGA) infant. The client asks how this could have happened. The nurse explains that risk factors for SGA infants include (Select all that apply): a. maternal hypotension b. chromosomal anomalies c. fetal infections d. maternal smoking e. severe maternal malnutrition

b. chromosomal anomalies c. fetal infections d. maternal smoking e. severe maternal malnutrition Rationale: Risk factors for SGA infants include congenital malformations, chromosomal anomalies, genetic factors, multiple gestations, fetal infections, poor placental function, maternal PREECLAMPSIA, severe diabetes, maternal smoking, maternal drug or alcohol abuse, and severe maternal malnutrition.

A nurse is assessing a client at risk for placenta previa. The nurse knows that the following risk factors increase her chance of placenta previa (Select all that apply): a. African American ethnicity b. cigarette smoking c. female fetus d. older age e. previous cesarean birth

b. cigarette smoking d. older age e. previous cesarean birth Rationale: Asian ethnicity, not African American ethnicity, is a risk factor for placenta previa. Male fetus, not female fetus, is a risk factor for placenta previa. Other risk factors include current use of cocaine, multiparas, and prior uterine surgery.

A nurse is preparing an educational workshop on preterm birth for couples who wish to conceive. Which topics could the nurse potentially cover (Select all that apply)? a. the benefits of epidural analgesia b. consequences of preterm birth c. signs and symptoms of preterm labor d. duration of normal pregnancy e. sexual positions that increase the risk of preterm birth

b. consequences of preterm birth c. signs and symptoms of preterm labor d. duration of normal pregnancy Rationale: The benefits of epidural analgesia would not be appropriate to include in a workshop about preterm labor. Sexual positions have no bearing on preterm birth. Other topics include role of early and regular prenatal care and conditions that increase risk for preterm birth.

The nurse is discussion the disruption of hormone secretion with a client who is attempting to become pregnant. The nurse explains that this could be caused by which of the following factors (Select all that apply)? a. cirrhosis b. cranial tumors c. obesity d. stress e. osteoarthritis

b. cranial tumors c. obesity d. stress Rationale: Disruption of hormone secretion or of the ovarian or endometrial responses to hormone secretion can be caused by cranial tumors, stress, obesity, anorexia, systemic disease, and abnormalities of the ovaries or other endocrine glands.

A client is in labor and is receiving oxytocin. She begins experiencing tachysystole. Which nursing interventions could the nurse perform to correct this (Select all that apply)? a. increase her dose of oxytocin b. decrease or stop her dose of oxytocin c. draw her a warm bath d. prepare for imminent birth e. position her supine with her legs flat

b. decrease or stop her dose of oxytocin c. draw her a warm bath Rationale: If she is experiencing tachysystole, the oxytocin could be the cause, so increasing the dose could intensify the already high uterine resting tone. Tachysystole usually occurs in the active phase during the first stage of labor, so preparing for imminent birth is not necessary. Positioning her supine is contraindicated as it could cause hypotension and increase her symptoms.

The nurse is providing community teaching on maternal and fetal effects of bath salts during pregnancy. Which of the following should the nurse include (Select all that apply)? a. maternal dysphoria b. decreased need for maternal sleep c. decreased maternal alertness d. maternal hallucinations e. bradycardia

b. decreased need for maternal sleep d. maternal hallucinations Rationale: Side effects of bath salts include decreased need for maternal sleep, maternal hallucinations, INCREASED MATERNAL ALERTNESS, TACHYCARDIA, maternal hypertension, stroke, acute myocardial infarction, gastric reflux, constipation, and delusions. Little is known about their effects on fetal development, but it is likely that they would be harmful to the developing fetus due to the high incidence of adverse effects in the mother.

A client is scheduled for a first-trimester ultrasonography. The nurse knows that this procedure could be indicated to (Select all that apply): a. determine fetal presentation b. determine gestational age c. determine the location of maternal anatomy d. confirm pregnancy e. confirm genetic abnormalities

b. determine gestational age c. determine the location of maternal anatomy d. confirm pregnancy Rationale: First trimester ultrasonography is indicated to determine gestational age and the location of maternal anatomy; confirm pregnancy and number and viability of fetuses; verify the location of the pregnancy; and identify markers of nuchal translucency, which suggest chromosomal abnormalities.

A client is scheduled for an amniocentesis. The nurse knows that this procedure is performed for the following indications (Select all that apply): a. determining fetal weight b. determining fetal lung maturity c. identification of chromosomal abnormalities d. confirmation of fetal anatomy e. identification of fetal infection

b. determining fetal lung maturity c. identification of chromosomal abnormalities e. identification of fetal infection Rationale: An amniocentesis involves aspiration of amniotic fluid and cannot determine fetal weight or anatomy.

The nurse is discussing coronary artery disease with a female client. The nurse knows that risk factors for coronary artery disease in women include (Select all that apply): a. high levels of HDL cholesterol b. diabetes mellitus c. obesity d. age older than 45 e. postmenopause status

b. diabetes mellitus c. obesity e. postmenopause status Rationale: Risk factors for coronary artery disease in women include cigarette smoking; hypertension; dyslipidemia; cholesterol ≥240 mg/dL; HDL <50 mg/dL; triglyceride >150 mg/dL; diabetes mellitus; overweight and obesity; sedentary lifestyle; poor nutrition, especially a diet high in saturated fat and cholesterol but low in fiber and fruit; AGE OLDER THAN 60; postmenopause status; family history of coronary artery disease.

A client who is 24 weeks of gestation is admitted to the emergency department with complaints that lead the nurse to suspect a possible myocardial infarction (MI). Which symptom may bring the nurse to this conclusion? a. radiating leg pain b. diaphoresis c. resting dyspnea d. hunger

b. diaphoresis Rationale: Symptoms of MI include radiating substernal chest pain, exertional dyspnea, and nausea.

The nurse is assessing a client with preeclampsia. The nurse knows that the following symptoms may be precursors of a seizure (Select all that apply): a. epigastric pain b. drowsiness c. diplopia d. continuous headache e. mental confusion

b. drowsiness d. continuous headache e. mental confusion Rationale: Epigastric pain is an ominous symptom that indicates an increase risk for liver rupture. Diplopia could indicate arterial spasms and edema of the retina.

The nurse is assessing for dehydration in the preterm infant. The nurse knows to look for which of the following signs and symptoms of dehydration (Select all that apply)? a. urine specific gravity <1.001 b. dry skin and mucous membranes c. bulging anterior fontanel d. poor tissue turgor e. hypotension

b. dry skin and mucous membranes d. poor tissue turgor e. hypotension Rationale: Signs of dehydration in the preterm infant include urine output <1 mL/kg/h; URINE SPECIFIC GRAVITY >1.012; weight loss greater than expected; dry skin and mucous membranes; SUNKEN ANTERIOR FONTANEL; poor tissue turgor; hypotension; and elevated sodium, protein, and hematocrit levels.

The nurse is providing teaching to a mother of an infant with phenylketonuria (PKU). The nurse explains that clinical manifestations to look for as her child ages include (Select all that apply): a. hypotonia b. eczema c. lethargic behavior d. cognitive impairment e. hyperpigmentation of the skin

b. eczema d. cognitive impairment Rationale: Manifestations of PKU in older children include eczema; HYPERTONIA; HYPERACTIVE BEHAVIOR; cognitive impairment; and HYPOPIGMENTATION of the hair, skin, and nails.

A nurse is caring for a client with hyperemesis gravidarum (HEG). The nurse knows that this client is at increased risk for (Select all that apply): a. hyperkalemia b. elevated levels of ketones c. loss of 5% or more of pregnancy weight d. short-term hepatic dysfunction e. edema

b. elevated levels of ketones c. loss of 5% or more of pregnancy weight d. short-term hepatic dysfunction Rationale: HEG may cause hypokalemia, not hyperkalemia. The client with HEG experiences dehydration, not edema. Other complications include acidosis from starvation, alkalosis rom loss of HCl in gastric fluids, coagulation disorders from deficiency of vitamin K, and encephalopathy from deficiency of thiamine.

A nurse is providing home care guidelines to a client about measures to avoid preterm labor. Which guidelines should the nurse include (Select all that apply)? a. rest in the supine position to promote relaxation b. empty the bladder frequently to avoid early uterine contractions c. drink an adequate amount of water to improve hydration d. avoid folic acid as this could cause early uterine contractions e. avoid all physical activity for the duration of the pregnancy

b. empty the bladder frequently to avoid early uterine contractions c. drink an adequate amount of water to improve hydration Rationale: Clients should rest in the side-lying position to promote uterine blood flow. Folic acid is an important prenatal vitamin as it can promote closure of the neural tube. Prolonged limitation of physical activity is not usually beneficial or safe for prevention of preterm labor.

The nurse is discussing signs and symptoms of ductal ectasia with a perimenopausal client. The nurse explains that ductal ectasia causes an inflammatory process that results in the following (Select all that apply): a. firm, freely movable nodules b. enlarged axillary nodes c. nipple retraction d. nipple discharge e. dry, flaky areolas

b. enlarged axillary nodes c. nipple retraction d. nipple discharge Rationale: Ductal ectasia is characterized by dilation of the collecting ducts, which become distended and filled with cellular debris. This initiates an inflammatory process that results in a mass near the areola that feels firm and irregular, enlarged axillary lymph nodes, and nipple retraction and discharge.

A client in labor is experiencing ineffective contractions. The nurse knows that this could be caused by (Select all that apply): a. hyperglycemia b. excessive analgesia c. fluid and electrolyte imbalance d. maternal fatigue e. uterine over-distention

b. excessive analgesia c. fluid and electrolyte imbalance d. maternal fatigue e. uterine over-distention Rationale: Hypoglycemia may cause ineffective contractions, not hyperglycemia. Other causes include maternal inactivity, maternal catecholamines secreted in response to stress or pain, disproportion between the maternal pelvis and fetal presenting part, and poor application of the presenting part to the cervix.

The nurse is providing community teaching on fetal effects of caffeine use during pregnancy. Which of the following should the nurse include? a. fetal depression b. fetal stimulation c. macrosomia d. acencephaly

b. fetal stimulation Rationale: Caffeine crosses the placental barrier and stimulates the fetus. Teratogenic effects are undocumented.

A nurse is assessing a client in labor for Triple I. The nurse knows that which of the following parameters meet the criteria for a diagnosis for Triple I (Select all that apply)? a. fetal bradycardia b. fetal tachycardia c. fetal tachysystole d. maternal fever (>102.2°F) e. clear fluid emanating from the cervical os

b. fetal tachycardia d. maternal fever Rationale: Neither fetal bradycardia nor fetal tachysystole meet the criteria for Triple I. Clear fluid emanating from the cervical os is normal, while purulent fluid emanating from the cervical os is indicative of Triple I. Other parameters include maternal white blood cell count greater than 15,000 in the absence of corticosteroids and biochemical or microbiologic amniotic fluid results consistent with microbial invasion of the amniotic cavity.

A nurse is discussing fibroadenomas with an adolescent female client. The nurse describes them as: a. firm, immobile nodules that are tender b. firm, freely mobile nodules that may or may not be tender c. soft, immobile nodules that are not tender d. soft, freely mobile nodules that may or may not be tender

b. firm, freely mobile nodules that may or may not be tender Rationale: Fibroadenomas do not change during the menstrual cycle. They are generally located in the upper, outer quadrant of the breast, and more than one is often present.

The nurse is teaching a group of parents about the physical effects of alcohol on fetal facial development. Which effects should the nurse include (Select all that apply)? a. thick upper lip b. flat midface with a low nasal bridge c. anencephaly d. short palpebral fissures e. indistinct philtrum

b. flat midface with a low nasal bridge d. short palpebral fissures e. indistinct philtrum Rationale: Facial effects include thin upper lip and microcephaly.

A client just gave birth to a newborn that displayed shoulder dystocia during the second stage of labor. Which of the following could be a newborn complication of such a birth? a. macrosomia b. fractured clavicle c. fractured femur d. cleft palate

b. fractured clavicle Rationale: The newborn's weight is not affected by shoulder dystocia. A fractured femur is not a cause of shoulder dystocia. A cleft palate is a deformity that occurs in utero and is not affected by complications during delivery.

A client is told that her pelvis has a round, cylindric shape throughout, giving her the best prognosis for vaginal birth. The nurse knows that this shape is called: a. android b. gynecoid c. platypelloid d. anthropoid

b. gynecoid Rationale: An android pelvis is heart-or triangular-shaped with narrow diameters throughout and has a poor prognosis for vagina birth. A gynecoid pelvis has wide diameters and gentle curves throughout, making it ideal for vaginal birth. A platypelloid pelvis is flattened with a wide pubic arch and has a poor prognosis for vaginal birth. An anthropoid pelvis has a long, narrow oval shape with a narrow pubic arch and is more favorable than android or platypelloid, but creates a higher chance of the fetus being born in occiput posterior position.

A client is in labor and her fetus is in the occiput posterior position. Which of the following positions could the nurse assist the client into to promote fetal head rotation to the occiput anterior position? a. semi-Fowler's b. hands and knees c. supine d. side-lying on the same side of the fetal occiput

b. hands and knees Rationale: A semi-Fowler's position would not promote rotation. Rocking the pelvis back and forth while on hands and knees promotes rotation. A supine position would not promote rotation and is contraindicated due to the risk of hypotension. A side-lying position on the opposite side of the fetal occiput is appropriate. Other positions include squatting, sitting, kneeling, or standing while leaning forward.

The nurse is caring for an infant with cytomegalovirus. Which signs and symptoms should the nurse expect (Select all that apply)? a. large for gestational age b. hearing loss c. small liver d. learning impairment e. jaundice

b. hearing loss d. learning impairment e. jaundice Rationale: Signs and symptoms of cytomegalovirus include SMALL FOR GESTATIONAL AGE, ENLARGED LIVER, CNS abnormalities, jaundice, learning impairment, hearing loss, purpura, chorioretinitis, microcephaly, and seizures. Most are asymptomatic at birth.

The nurse is providing a community workshop on adolescent pregnancy. Which of the following should the nurse include as potential risk factors for adolescent pregnancy (Select all that apply)? a. teens with siblings b. homeless teens c. teens in the foster system d. teens in the juvenile justice system e. teens without siblings

b. homeless teens c. teens in the foster system d. teens in the juvenile justice system Rationale: The number of siblings doesn't appear to have any bearing on the risk of adolescent pregnancy.

A nurse educator is teaching a group of nursing students about the causes of a prolapsed umbilical cord. Which of the following should the nurse educator include as possible causes of a prolapsed umbilical cord (Select all that apply)? a. a fetus at a low station b. hydramnios c. shoulder presentation d. a very small or preterm fetus e. longitudinal lie

b. hydramnios d. a very small or preterm fetus Rationale: A prolapsed umbilical cord may be caused by a fetus that remains at a HIGH STATION, BREECH PRESENTATION, TRANSVERSE LIE, hydramnios, or a very small or preterm fetus.

The nurse is caring for an infant with toxoplasmosis. Which signs and symptoms should the nurse expect (Select all that apply)? a. polycythemia b. hydrocephalus c. enlarged liver and spleen d. macrosomia e. cyanosis

b. hydrocephalus c. enlarged liver and spleen Rationale: Signs and symptoms of toxoplasmosis include fetal growth restriction, LOW BIRTH WEIGHT, preterm, THROMBOCYTOPENIA, enlarged liver and spleen, JAUNDICE, cerebral calcifications, encephalitis, seizures, microcephaly, hydrocephalus, and chorioretinitis.

The nurse knows that maternal indications for antepartum fetal surveillance include (Select all that apply): a. primigravida b. hypertensive disorders c. diabetes d. cyanotic heart disease e. advanced maternal age

b. hypertensive disorders c. diabetes d. cyanotic heart disease e. advanced maternal age Rationale: Primigravida is not an indication for antepartum fetal surveillance. Other maternal indications include chronic renal disease, cholestasis, systemic lupus erythematosus, thrombophilia, substance abuse, black race, previous stillbirth, and obesity.

The nurse has checked the glucose of an infant of a diabetic mother (IDM) and has discovered that it is low. The nurse initiates gavage feeding once it is established that the infant does not suck well. When should the nurse recheck the infant's glucose? a. in 15 to 30 minutes b. in 30 to 45 minutes c. in 45 minutes to 1 hour d. in 1-2 hours

b. in 30 to 45 minutes Rationale: Gavage feeding may be used if the infant does not suck well or if respirations are rapid. The glucose level is rechecked in 30 to 45 minutes.

The nurse is assessing a client who is suspected of recent use of cocaine. The nurse knows to look for the following symptoms (Select all that apply): a. hypotension b. irregular respirations c. profuse sweating d. decreased body temperature e. pinpoint pupils

b. irregular respirations c. profuse sweating Rationale: Symptoms associated with recent cocaine use include hypertension, increased body temperature, and dilated pupils. Other signs include maternal tachycardia and sudden onset of severely painful contractions; fetal tachycardia, excessive activity, bradycardia, and late decelerations. The client may be angry, caustic, or abusive to those attempting to provide care.

The nurse is assessing for signs of infection in a newborn. Which of the following are positive signs of infection (Select all that apply)? a. poor skin turgor b. jitteriness c. apnea d. constipation e. hypertension

b. jitteriness c. apnea Rationale: Signs and symptoms of infection include temperature instability (usually low), rash, tachypnea, respiratory distress (nasal flaring, retractions, grunting), apnea, color changes (cyanosis, pallor, mottling), tachycardia, HYPOTENSION, decreased peripheral perfusion, EDEMA, decreased oral intake, vomiting, excessive gastric residuals, DIARRHEA, abdominal distention, hypoglycemia or hyperglycemia, decreased or increased muscle tone, lethargy, jitteriness, irritability, full-fontanel, and high-pitched cry.

The nurse is providing community teaching on maternal and fetal effects of opioid use during pregnancy. Which of the following should the nurse include (Select all that apply)? a. maternal polycythemia b. kidney disease c. meconium aspiration d. maternal thrombosis e. preterm labor

b. kidney disease c. meconium aspiration d. maternal thrombosis e. preterm labor Rationale: Maternal anemia, not polycythemia, is an effect of opioid use during pregnancy. Other effects include maternal malnutrition, hepatitis, cardiac disease, heart and lung infections, and severe respiratory distress; increased incidence of maternal STDs and HIV exposure; spontaneous abortion; fetal growth restriction; low birth weight; neonatal abstinence syndrome (seizures, birth defects, and dysfunctions in brain organization); perinatal asphyxia; fetal or neonatal death; SIDS; and child abuse and neglect.

The nurse is providing community teaching on maternal and fetal effects of tobacco use during pregnancy. Which of the following should the nurse include (Select all that apply)? a. macrosomia b. low birth weight c. prematurity d. placental abruption e. premature rupture of membranes

b. low birth weight c. prematurity d. placental abruption e. premature rupture of membranes Rationale: Tobacco can cause low birth weight, not macrosomia. Other effects include neurodevelopmental problems, increased incidence of SIDS, perinatal mortality, decreased placental perfusion, maternal anemia, preterm labor, and spontaneous abortion.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding condoms (Select all that apply)? a. can be used multiple times b. low cost per single use c. no prescription needed d. protects against STDs e. can be carried discreetly

b. low cost per single use c. no prescription needed d. protects against STDs e. can be carried discreetly Rationale: CAN ONLY BE USED ONCE.

The nurse is preparing to administer an anticonvulsant medication to a client with severe preeclampsia. The nurse knows that the first-line medication for the prevention of seizures in severely preeclamptic patients is: a. phenytoin b. magnesium sulfate c. calcium gluconate d. diazepam

b. magnesium sulfate Rationale: Phenytoin and diazepam are not recommended as first-line agents because of their decreased efficacy compared with magnesium. Calcium gluconate is the antidote for magnesium sulfate toxicity.

The nurse is acting as a communicator to a client who is in labor and recently used heroin. Which technique should the nurse use to effectively communicate with this client? a. speak very loudly because the client's hearing will be diminished b. maintain eye contact so the client is able to focus on instructions c. ask the client what she wants to do because she will not want to listen to instructions d. provide no explanations because the client will not understand

b. maintain eye contact so the client is able to focus on instructions Rationale: There is no reason to talk any louder to this client than any other client. The nurse should state firmly what is happening and exactly what she wants the woman to do with concrete explanations so that the client understands.

The nurse is assessing a client for endometritis. The nurse knows to look for which of the following clinical manifestations (Select all that apply)? a. temperature ≥99.5°F b. malaise c. abdominal pain and cramping d. purulent lochia e. bradycardia

b. malaise c. abdominal pain and cramping d. purulent lochia Rationale: Signs and symptoms of endomitritis include TEMPERATURE ≥100.4°F, chills, malaise, anorexia, abdominal pain and cramping, uterine tenderness, purulent lochia, TACHYCARDIA, and subinvolution.

The nurse is assessing a postpartum client for retention of placental fragments. The nurse knows that predisposing factors of placental retention include (Select all that apply): a. prolonged delivery of the placenta b. manual removal of the placenta c. previous vaginal birth d. uterine leiomyomas e. placenta accretia

b. manual removal of the placenta d. uterine leiomyomas e. placenta accretia Rationale: Attempts to deliver the placenta before It separates from the uterine wall, manual removal of the placenta, placenta accretia, previous CESAREAN birth, and uterine leiomyomas are primary predisposing factors for retention of placental fragments.

The nurse is assessing a client at risk for placental abruption. The nurse knows that the risk factors for placental abruption include (Select all that apply): a. primigravida status b. maternal cigarette smoking c. abdominal trauma d. maternal hypotension e. maternal use of cocaine

b. maternal cigarette smoking c. abdominal trauma e. maternal use of cocaine Rationale: Multigravida status, not primigravida status, is a risk factor for placental abruption. Maternal hypertension, not maternal hypotension, as a risk factor for placental abruption. Maternal use of cocaine is the leading cause of placental abruption. Other risk factors include premature rupture of membranes and history of previous premature separation of the placenta.

A client in the second stage of labor is displaying ineffective pushing with contractions. The nurse knows that this could be the result of (Select all that apply): a. oxytocin administration b. maternal exhaustion c. decreased or absent urge to push d. laboring down e. psychological unreadiness to "let go" of her baby

b. maternal exhaustion c. decreased or absent urge to push e. psychological unreadiness to "let go" of her baby Rationale: Ineffective pushing with contractions may be caused by maternal exhaustion, psychological unreadiness to "let go" of her baby, use of nonphysiologic pushing techniques and positions (i.e., supine), fear of injury because of pain and tearing sensations felt by the mother when she pushes, and analgesia or anesthesia that suppresses the woman's urge to push.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding the sponge (Select all that apply)? a. must be inserted right before coitus b. may cause irritation c. must remain in place for 3 hours after intercourse d. risk for toxic shock syndrome e. requires a prescription

b. may cause irritation d. risk for toxic shock syndrome Rationale: Can be inserted SEVERAL HOURS BEFORE COITUS. Must remain in place for 6 HOURS AFTER INTERCOURSE. NO PRESCRIPTION REQUIRED.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding emergency contraception (Select all that apply)? a. all require a prescription b. may cause nausea c. must be taken within 24 hours of unprotected intercourse d. no protection against STDs e. higher risk for clot formation

b. may cause nausea d. no protection against STDs Rationale: Some emergency contraceptives are AVAILABLE WITHOUT A PRESCRIPTION. Emergency contraceptives must be taken WITHIN 120 HOURS OF UNPROTECTED SEX. There is NO RISK OF CLOT FORMATION.

The nurse is caring for a client with chronic hypertension. The nurse knows that the drug of choice for chronic hypertension is: a. labetalol b. methyldopa c. captopril d. hydralazine

b. methyldopa Rationale: Methyldopa is the drug of choice for chronic hypertension because of its record of safety and effectiveness in pregnancy.

A nurse educator is providing teaching to a group of nursing students about spontaneous abortion. The nurse educator includes the following as subgroups of spontaneous abortion (Select all that apply): a. late b. missed c. inevitable d. early e. threatened

b. missed c. inevitable e. threatened Rationale: Late and early are not subgroups of spontaneous abortion. The 6 subgroups are threatened, inevitable, incomplete, complete, missed, and recurrent.

A nurse is caring for a client who is experiencing postpartum hemorrhage. Which position should the nurse place the client in to increase venous return and maintain cardiac output? a. full Trendelenburg b. modified Trendelenburg c. full Fowler's d. semi-Fowler's

b. modified Trendelenburg Rationale: A modified Trendelenburg's position may be used with the head slightly elevated and the legs elevated 10-30° to increase blood return from the legs.

A client at risk for preterm labor asks the nurse about complete activity restrictions. The nurse knows that adverse effects of complete activity restrictions during pregnancy may include (Select all that apply): a. hypertension b. muscle weakness c. psychological effects d. sleep changes e. diuresis

b. muscle weakness c. psychological effects d. sleep changes e. diuresis Rationale: Complete activity restrictions could cause orthostatic hypotension, not hypertension.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding the vaginal contraceptive ring (NuvaRing) (Select all that apply)? a. no side effects b. no fitting required c. can remain in place for 3 months at a time d. unrelated to coitus e. dissolves over time

b. no fitting required d. unrelated to coitus Rationale: May include SIDE EFFECTS SUCH AS HEADACHE AND VAGINITIS. Can remain in place for 3 WEEKS AT A TIME. MUST REMEMBER WHEN TO REMOVE AND WHEN TO INSERT.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding the cervical cap (Select all that apply)? a. inexpensive b. no pressure against bladder as with diaphragm c. can remain in place up to 24 hours d. can be removed immediately after coitus e. provides some protection against STDs

b. no pressure against bladder as with diaphragm e. provides some protection against STDs Rationale: INITIALLY EXPENSIVE. Can remain in place up to 48 HOURS. Must remain in place for AT LEAST 6 HOURS AFTER COITUS.

A nurse is caring for a client who is at risk for late preterm birth. The nurse knows that risk factors for late preterm birth include (Select all that apply): a. vaginal birth b. obesity c. preeclampsia d. multifetal gestations e. young maternal age

b. obesity c. preeclampsia d. multifetal gestations Rationale: Contributing factors in late preterm birth include elective and medically indicated inductions and CESAREAN BIRTHS, preterm labor, premature rupture of membranes, preeclampsia, multifetal pregnancies, obesity, assisted reproductive technology, ADVANCED MATERNAL AGE, and inaccurate estimate of gestational age before birth.

The nurse is assessing a client at her first prenatal visit. The nurse knows that the following factors put the client at risk for developing gestational diabetes (GDM) (Select all that apply): a. history of diabetes in a second-degree relative b. overweight c. history of abnormal glucose intolerance d. history of polycystic ovary syndrome (PCOS) e. maternal age older than 35 years

b. overweight c. history of abnormal glucose intolerance d. history of polycystic ovary syndrome (PCOS) Rationale: Risk factors for GDM include history of diabetes in a first-degree relative and maternal age older than 25 years.

A nurse is obtaining a semen analysis to determine the fertility of the client. Which of the following findings are good signs of fertility (Select all that apply)? a. semen volume: ≥1.5 mL b. pH: 7.2-7.8 c. sperm concentration: ≥15 million/mL d. motility: ≥50% with normal forms e. morphology: ≥30% with normal forms f. viability: ≥40% live g. liquefaction: within 30 minutes h. leukocytes: <3 million/mL

b. pH: 7.2-7.8 d. motility: ≥50% with normal forms e. morphology: ≥30% with normal forms g. liquefaction: within 30 minutes Rationale: Semen analysis should include the following: SEMEN VOLUME: ≥2 mL pH: 7.2-7.8 SPERM CONCENTRATION: ≥20 million/mL Motility: ≥50% with normal forms Morphology: ≥30% with normal forms VIABILITY: ≥50% live Liquefaction: within 30 minutes LEUKOCYTES: <1 million/mL

The nurse is explaining the difference between various cardiac defects. Which of the following is considered an acyanotic defect? a. coarctation of the aorta b. patent ductus arteriosus c. transposition of the great vessels d. patent foramen ovale

b. patent ductus arteriosus Rationale: Coarctation of the aorta is a defect with obstruction of blood outflow. Transposition of the great vessels is a cyanotic defect. Patent foramen ovale is a left-to-right shunting defect.

The nurse is providing teaching to a client about medical conditions that may reduce his ability to maintain an erection. Which medical condition should the nurse include (Select all that apply)? a. psoriasis b. peripheral vascular disease c. glaucoma d. IBS

b. peripheral vascular disease Rationale: Peripheral vascular disease, from cardiovascular disease or diabetes, reduces the amount of blood entering the penis and thereby reduces the ability to maintain an erection.

The nurse is discussing risk factors for breast cancer with a female client. Which risk factors will the nurse include (Select all that apply)? a. early menopause b. personal history of breast cancer c. first pregnancy after 35 years d. obesity e. excessive alcohol consumption

b. personal history of breast cancer d. obesity e. excessive alcohol consumption Rationale: Risk factors for pregnancy include early menarche or LATE MENOPAUSE; nulliparity or first pregnancy AFTER 30 YEARS; personal history of breast cancer; genetic risk factors such as family history in first-degree relatives, family history of other cancer, mutations in genes; previous irradiation of the chest area as a child or a young woman as treatment for another cancer; previous abnormal breast biopsy results such as atypical hyperplasia and fibrocystic changes with proliferative changes; long-term hormone replacement therapy with estrogen and progesterone; excessive alcohol consumption; overweight or obesity; and physical inactivity.

The nurse caring for an infant with gastroschisis knows that management includes: a. a gastric tube placed to decrease fluid in the stomach b. placing the infant's torso into a sterile plastic bag c. surgery to remove the affected section of intestines d. enteral nutrition

b. placing the infant's torso into a sterile plastic bag Rationale: A gastric tube is placed to decrease AIR IN THE STOMACH. Surgery is performed to REPLACE INTESTINES IN THE ABDOMINAL CAVITY. PARENTERAL NUTRITION is necessary.

A client with a multifetal pregnancy is in labor. The nurse knows that this client is at a higher risk for: a. preeclampsia b. postpartum hemorrhage c. ineffective pain management d. obesity

b. postpartum hemorrhage Rationale: A client is not at a higher risk for preeclampsia. With a multifetal pregnancy, the uterus can become overdistended and may not contract evenly or with great force. This can increase the risk of postpartum hemorrhage if the contractions are not strong enough. A client's ability to manage pain is not determined by the number of fetuses she carries. A client may gain more weight during a multifetal pregnancy because she has two fetuses to feed, but that does not put her at an increased risk for obesity.

A nurse is caring for a client with premature rupture of membranes (PROM). The nurse knows that the client is at higher risk for: a. postpartum hemorrhage b. postpartum infection c. hypertension d. emergency cesarean

b. postpartum infection Rationale: If the membranes are ruptured for a long period of time, there is a risk of bacteria entering the uterus from the vaginal canal. A potential risk to the newborn is neonatal sepsis.

The nurse is assessing a client with diabetes. The nurse knows that the fetus may be at risk for the following complications (Select all that apply): a. hyperglycemia b. preterm labor c. hypercalcemia d. macrosomia e. anemia

b. preterm labor d. macrosomia Rationale: Increased fetal and neonatal risks with diabetes include HYPOGLYCEMIA, HYPOCALCEMIA, POLYCYTHEMIA, preterm labor, macrosomia, congenital anomalies, perinatal death, intrauterine fetal growth restriction, birth injury, hyperbilirubinemia, and respiratory distress syndrome.

A nurse caring for a client with gestational trophoblastic disease (hydatidiform mole) knows that this disease is characterized by: a. a mole on the labia minora b. proliferation and edema of the chorionic villi c. proliferation and edema of the fallopian tubes d. purulent vaginal discharge

b. proliferation and edema of the chorionic villi Rationale: Gestational trophoblastic disease occurs when trophoblasts develop abnormally and is characterized by proliferation and edema of the chorionic villi. The fluid-filled villi form grapelike clusters of tissue that can rapidly grow large enough to fill the uterus to the size of an advanced pregnancy.

A nurse is caring for a client who is at risk for thrombosis. The nurse knows that which of the following factors increase the client's risk (Select all that apply)? a. vaginal birth b. prolonged labor c. edema d. use of forceps e. sepsis

b. prolonged labor d. use of forceps e. sepsis Rationale: Factors that increase the risk for thrombosis include inactivity, prolonged bed rest, obesity, CESAREAN BIRTH, sepsis, smoking, history of previous thrombosis, varicose veins, diabetes mellitus, trauma, prolonged labor, prolonged time in stirrups in second stage of labor, maternal age older than 35 years, increased parity, DEHYDRATION, first-degree relative with thrombosis, use of forceps, antiphospholipid antibody syndrome, inherited thrombophilias, and air travel.

A nurse is providing care for a client who is worried about having a preterm birth. Which measures could the nurse take to prevent preterm birth (Select all that apply)? a. encourage the client to drink a glass of red wine every night b. promote adequate nutrition c. teach the client to avoid drinking too much water in case of hypertension d. teach the client about the signs and symptoms of preterm labor e. encourage the client and her partner to take an active approach in seeking care

b. promote adequate nutrition d. teach the client about the signs and symptoms of preterm labor e. encourage the client and her partner to take an active approach in seeking care Rationale: The nurse should encourage the client to AVOID ALCOHOL, maintain adequate nutrition, drink PLENTY OF WATER, know signs and symptoms of preterm labor, and take an active with her partner approach in seeking care.

A nurse is caring for a client diagnosed with preeclampsia. The nurse knows that maternal complications associated with preeclampsia include (Select all that apply): a. polyuria b. pulmonary edema c. anemia d. visual disturbances, blindness e. hypoglycemia

b. pulmonary edema c. anemia d. visual disturbances, blindness e. hypoglycemia Rationale: Oliguria, not polyuria, is a maternal complication of preeclampsia. Other maternal complications include decreased intravascular volume, severe hypertension, congestive heart failure, hypoxemia, acute renal failure, impaired drug metabolism and excretion, hemolysis, decreased oxygen-carrying capacity, thrombocytopenia, coagulation defects, seizures, cerebral edema, intracerebral hemorrhage, stroke, hepatocellular dysfunction, hepatic rupture, coagulation defects, and placental abruption.

The nurse educator is teaching a group of nursing students about characteristics of preterm infants. Which characteristics should the nurse educator include (Select all that apply)? a. small head compared with the rest of the body b. red and translucent skin c. feeble cry d. very little body hair e. flat and soft ears

b. red and translucent skin c. feeble cry e. flat and soft ears Rationale: Characteristics of preterm infants include less developed flexor muscles and muscle tone, limp extremities, LARGE HEAD compared with the rest of the body, red and translucent skin, barely perceptible nipples and areola, LANUGO (body hair) may be abundant, absent plantar creases, flat pinnae of the ears, large clitoris not covered by labia majora in females, undescended testes with a small and smooth scrotal sac in males, easily exhausted, and feeble cry.

A nurse is assessing a client who is displaying maternal exhaustion. Which of the following interventions are appropriate for the client at this time (Select all that apply)? a. turn on the overhead lights so that she can stay awake b. reduce noise by closing the door c. position the client to promote comfort d. encourage her to pace so she can stay awake e. offer her a back rub to reduce muscle tension

b. reduce noise by closing the door c. position the client to promote comfort e. offer her a back rub to reduce muscle tension Rationale: The overhead lights should be shut off to promote relaxation. Pacing will only increase maternal exhaustion. Other interventions include a warm shower or bath, maintaining a comfortable maternal temperature, using a birthing ball, warmth to her back, firm sacral pressure to reduce back pain, maintaining IV fluids at the rate ordered to provide fluid and electrolytes, and providing clear liquids such as juice to moisten the client's mouth and replenish her energy.

The client is discussion fertility with a couple trying to become pregnant. The nurse explains that a woman's fertility depends on which of the following (Select all that apply)? a. weight b. regular production of normal ova c. an open path from her cervix through the uterus and fallopian tube d. hydration e. a uterine endometrium that supports the pregnancy after implantation

b. regular production of normal ova c. an open path from her cervix through the uterus and fallopian tube e. a uterine endometrium that supports the pregnancy after implantationRationale: A woman's fertility depends on regular production of normal ova, an open path from her cervix through the uterus and fallopian tube to permit fertilization and movement of the embryo into the uterus for implantation, and a uterine endometrium that supports the pregnancy after implantation.

A nurse is caring for a client with a prolapsed umbilical cord. Which action is the priority at this time? a. push the call light to summon help b. relieve pressure on the cord vaginally by pushing on the presenting part c. prepare for an ultrasound examination d. instruct the client to begin pushing now

b. relieve pressure on the cord vaginally by pushing on the presenting part Rationale: The immediate priority at this time is to relieve pressure on the cord as any amount of time that blood flow from the placenta to the fetus is occluded puts the fetus in immediate danger. The nurse should shout for help so that the client can be prepared for an ultrasound examination and cesarean delivery. A client with a prolapsed umbilical cord cannot give birth vaginally, as the prolonged occlusion of the umbilical cord could cause fetal distress and death.

A client with an ectopic tubal pregnancy is scheduled to undergo a salpingectomy. The nurse knows that this procedure involves: a. removal of the ectopic pregnancy from the fallopian tube b. removal of the fallopian tube c. removal of the ovary d. insertion of pitocin into the fallopian tube

b. removal of the fallopian tube Rationale: A linear salpingostomy is the removal of the ectopic pregnancy from the fallopian tube in an effort to salvage the tube. An oophrectomy is the removal of an ovary. There is no procedure in which pitocin is inserted into the fallopian tube.

The nurse is assessing a postpartum client for signs that she is recovering from preeclampsia. Which signs should the nurse expect (Select all that apply)? a. increased protein in urine b. return of blood pressure to normal c. resolution of abnormal laboratory values d. decreased urinary output e. crackles in the lung bases

b. return of blood pressure to normal c. resolution of abnormal laboratory values Rationale: Signs that the client is recovering from preeclampsia include decreased protein in urine, increased urinary output, and rapid reduction of edema. Crackles in the lung bases indicates pulmonary edema.

The nurse is assessing a client for HELLP syndrome. The nurse knows that the prominent symptom of HELLP syndrome is pain in the: a. right lower quadrant b. right upper quadrant c. left lower quadrant d. left upper quadrant

b. right upper quadrant Rationale: The prominent symptom of HELLP syndrome is pain in the right upper quadrant, the lower right chest, or the midepigastric area. Additional signs and symptoms include nausea, vomiting, and severe edema.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding a progestin implant (Select all that apply)? a. provides 5-year protection b. safe during lactation c. unrelated to coitus d. no major side effects e. body weight has no effect

b. safe during lactation c. unrelated to coitus e. body weight has no effect Rationale: The progestin implant provides 3-YEAR PROTECTION. A progestin implant may have IRREGULAR BLEEDING AS A MAJOR SIDE EFFECT.

A nurse is discussing diagnostic testing for infertility with a couple attempting to become pregnant. The nurse explains that early evaluation for the couple may include (Select all that apply): a. urinalysis b. semen analysis c. ultrasound imaging of internal reproductive organs d. precoital examination e. evaluation of cervical mucus

b. semen analysis c. ultrasound imaging of internal reproductive organs e. evaluation of cervical mucus Rationale: Early evaluation for a couple may include ovulation monitoring kit to identify if ovulation has occurred; evaluation of the cervical mucus to identify changes that occur with ovulation; hormone evaluations such as estrogen, progesterone, LH, FSH, and thyroid function; ultrasound imaging of internal reproductive organs; radiographic imaging to visualize uterine cavity and patency of the fallopian tubes; semen analysis; testicular examination to include ultrasound and/or biopsy; and POSTCOITAL examination.

The nurse is assessing a client for placenta previa. The nurse knows that the classic sign of placenta previa is: a. sudden onset of painful uterine bleeding in the first have of pregnancy b. sudden onset of painless uterine bleeding in the last half of pregnancy c. the presence of purulent vaginal drainage d. unexplained weight gain

b. sudden onset of painless uterine bleeding in the last half of pregnancy Rationale: The classic sign of placenta previa is the sudden onset of painless uterine bleeding In the last half of pregnancy. Many cases are diagnosed before bleeding occurs. Bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment thins and the cervix begins to dilate near term. Purulent vaginal discharge would indicate infection.

A nurse is assessing a client for cervical length and notes the length to be 22 mm. Which intervention might the provider order? a. supplemental vaginal estrogen b. supplemental vaginal progesterone c. estrogen suppression therapy d. progesterone suppression therapy

b. supplemental vaginal progesterone Rationale: A short cervical length is associated with low vaginal progesterone, so supplemental vaginal progesterone might be indicated at this time.

The nurse caring for an infant with respiratory distress syndrome (RDS) knows that the treatment for RDS includes administration of: a. gentamycin b. surfactant c. betamethazone d. erythromycin

b. surfactant Rationale: Surfactant therapy is administered through an endotracheal tube to improve respiratory compliance.

The nurse is assessing a postpartum client for early signs of hypovolemic shock following postpartum hemorrhage. Which of the following is one of the earliest signs of hypovolemic shock? a. anuria b. tachycardia c. cold and clammy skin d. confusion

b. tachycardia Rationale: Tachycardia is one of the earliest signs of hypovolemic shock. Other early signs include decreased blood pressure and narrow pulse pressure, tachypnea, and pallor. Late signs include COLD AND CLAMMY SKIN, anxiousness, CONFUSION, lethargy, oliguria, and ANURIA.

The nurse is assessing an infant for bronchopulmonary dysplasia (BPD). The nurse knows that which of the following manifestations indicate BPD (Select all that apply)? a. bradycardia b. tachypnea c. retractions d. respiratory alkalosis e. crackles

b. tachypnea c. retractions e. crackles Rationale: Clinical manifestations of BPD include TACHYCARDIA, tachypnea, retractions, crackles, wheezes, RESPIRATORY ACIDOSIS, cyanosis, increased secretions, bronchospasms, and pulmonary edema.

A nurse is caring for a client who is experiencing an abnormally prolonged pregnancy. Which interventions could the nurse perform at this time (Select all that apply)? a. administer magnesium sulfate b. teach the client about antepartum testing c. support the client's psychological and physical fatigue d. encourage the client to push e. provide nursing care related to specific procedures

b. teach the client about antepartum testing c. support the client's psychological and physical fatigue e. provide nursing care related to specific procedures Rationale: Magnesium sulfate is used to reduce uterine contractions in clients at risk for preterm labor. The client should not be encouraged to push until she is fully dilated and effaced and the provider is available to deliver her baby.

The nurse is caring for a client who's fetus is at risk for infection. Which factors put this fetus at risk (Select all that apply)? a. the client's membranes have been ruptured for longer than 8 hours b. the client is experiencing a prolonged labor c. the client is exhibiting signs of infection d. the client's amniotic fluid is stained green e. the client is GBS positive

b. the client is experiencing a prolonged labor c. the client is exhibiting signs of infection e. the client is GBS positive Rationale: Risk factors for infection include membranes that have been ruptured for longer than 12-18 HOURS, prolonged or precipitous labor, signs of maternal infection before labor, chorioamnionitis, FOUL-SMELLING AMNIOTIC FLUID (green fluid would be caused by meconium-staining and meconium is sterile), and a client who is GBS positive.

A newly licensed nurse is preparing to discharge a client who has a placenta previa. Which finding indicates that the client should not be discharged? a. the client is able to maintain bedrest at home b. the client lives 20 miles from the hospital c. the client can verbalize her understanding of the risks associated with placenta previa and how to manage her care d. the client has no evidence of active bleeding

b. the client lives 15 miles from the hospital Rationale: In order to be discharged safely, the client must be able to maintain bedrest at home, LIVE A SHORT DISTANCE FROM THE HOSPITAL, verbalize her understanding of the risks, have no evidence of active bleeding, and have emergency systems available for immediate transport to the hospital 24 hours a day.

A newly licensed nurse is caring for an infant who is receiving phototherapy for physiologic jaundice. Which of the following actions by the newly licensed nurse requires the preceptor to intervene? a. the newly licensed nurse places the halogen light farther away from the infant to prevent burning b. the newly licensed nurse applies lotion to the infant's skin to maintain hydration c. the newly licensed nurse covers the infant's eyes with patches to prevent retinal damage d. the newly licensed nurse encourages the mother to continue breastfeeding

b. the newly licensed nurse applies lotion to the infant's skin to maintain hydration Rationale: Although phototherapy increases insensible water loss from the skin, avoid the use of creams or lotions on the infant's skin due to the risk of burning.

The newly licensed nurse is preparing the parents for their first visit to the neonatal intensive care unit (NICU) setting. Which action by the newly licensed nurse requires the preceptor to intervene? a. the newly licensed nurse describes what the NICU environment looks like and sounds like b. the newly licensed nurse avoids talking about the infant's condition c. the newly licensed nurse describes the equipment using simple explanations d. the newly licensed nurse shows the parents photographs of their infant in the NICU

b. the newly licensed nurse avoids talking about the infant's condition Rationale: The newly licensed nurse should describe the infant. This includes the size, lack of fat, breathing problems, and weak cry. It should be explained that no sound of crying can be heard if the infant is intubated. Personal aspects should be included: "He's a real fighter" or "She makes the funniest faces during her feedings."

A newly licensed nurse is caring for a client who will be undergoing a nonstress test. Which actions by the newly licensed nurse require the preceptor to intervene (Select all that apply)? a. the newly licensed nurse asks the client which position is most comfortable for her and helps her into this position b. the newly licensed nurse places the client in a lithotomy position c. the newly licensed nurse explains that the client will receive oxytocin to induce contractions d. the newly licensed nurse explains to the client that she will remain on the fetal monitor for 2 or more hours e. the newly licensed nurse explains to the client that she will remain on the fetal monitor between 20 and 40 minutes.

b. the newly licensed nurse places the client in a lithotomy position c. the newly licensed nurse explains that the client will receive oxytocin to induce contractions d. the newly licensed nurse explains to the client that she will remain on the fetal monitor for 2 or more hours Rationale: Women are placed in a comfortable position to reduce the risk of an abnormal result. The client should remain on the fetal monitor for a minimum of 20 minutes but can stay on the monitor for up to 40 minutes.

The newly licensed nurse is caring for a client scheduled to have a first-trimester ultrasonography. Which action by the newly licensed nurse requires the preceptor to intervene? a. the newly licensed nurse places the client in a lithotomy position b. the newly licensed nurse places the client in a semi-Fowler's position c. the newly licensed nurse explains that a transvaginal probe will be inserted into the client's vagina d. the newly licensed nurse explains that the procedure will take approximately 10-15 minutes

b. the newly licensed nurse places the client in a semi-Fowler's position Rationale: The client should be placed in a lithotomy position, a transvaginal probe is used, and the procedure should last 10-15 minutes.

A client is scheduled for a percutaneous umbilical blood sampling (PUBS). The nurse knows that complications of PUBS include (Select all that apply): a. placenta previa b. thrombosis c. infection d. trisomy 21 e. umbilical cord laceration

b. thrombosis c. infection e. umbilical cord laceration Rationale: No evidence suggests that a PUBS will result in trisomy 21 or placenta previa. Other complications include umbilical cord hematoma, preterm labor resulting in emergent preterm delivery of a compromised fetus, preterm premature rupture of membranes, and pregnancy loss.

A nurse is caring for a client who is 1 hour postpartum. The client has saturated 2 perineal pads in bright red blood since birth. When assessing the fundus, the nurse notes that it is firm and at the umbilicus. What could be another reason for this client's bleeding? a. retained placental fragments b. uterine rupture c. distended bladder d. this is a normal finding

b. uterine rupture Rationale: Retained placental fragments would cause the fundus to be boggy and the pads saturated with brick-red blood. Distended bladder would cause the fundus to be boggy, displaced above and to the right of the umbilicus, and the pads saturated with brick-red blood. Bright red blood is not a normal finding and saturating 2 pads in under 1 hour indicates postpartum hemorrhage.

The nurse is teaching a teenage client about self-care during pregnancy. Which statement by the client indicates a need for further teaching? a. "I shouldn't smoke cigarettes while I'm pregnant." b. "I shouldn't drink alcohol while I'm pregnant." c. "I don't need to worry about using a condom since I'm already pregnant."

c. "I don't need to worry about using a condom since I'm already pregnant." Rationale: The client should still use a condom to prevent STDs.

The nurse is teaching a client with gestational diabetes (GDM) about hyperglycemia. The nurse knows that further teaching is needed when the client states: a. "I should lie down and rest if I develop hyperglycemia." b. "I should take 15 g of carbohydrates if I develop hyperglycemia." c. "I might need to be hospitalized if I develop hyperglycemia." d. "I may become pale if I develop hyperglycemia."

c. "I might need to be hospitalized if I develop hyperglycemia." Rationale: Hospitalization is often necessary to monitor blood glucose levels, for IV insulin administration to normalize glucose levels, and for treatment of any underlying infection.

The nurse is providing discharge teaching to the mother of a late preterm infant. Which statement by the mother indicates a need for further teaching? a. "I should look for signs of overstimulation and work to minimize them." b. "I should bring my baby in for a follow-up visit with my health care provider 24-48 hours after discharge." c. "I should dress my baby in the same amount of layers as I would wear. " d. "A car seat challenge test will be conducted before I leave."

c. "I should dress my baby in the same amount of layers as I would wear. " Rationale: Parents should dress their infants with ONE MORE LAYER than an adult would wear.

A nurse is providing nutritional teaching to a client with hyperemesis gravidarum (HEG). Which statement by the client indicates a need for further teaching? a. "I should add salt to my food to replace my chloride." b. "I should consume potassium-rich foods." c. "I should eat every 4-5 hours." d. "I should consume magnesium-rich foods."

c. "I should eat every 4-5 hours." Rationale: The client with HEG should eat every 1-2 hours.

The nurse is providing teaching about follow-up protocol to the client receiving treatment for gestational trophoblastic disease. Which statement by the client indicates that the teaching was effective? a. "I should have my beta-hCG reevaluated at 6 weeks postpartum. I should follow up 6 months after that, then in 2-3 months after that my beta-hCG is normal for 2 tests." b. "I should have my beta-hCG reevaluated at 6 months postpartum. I should follow up 6 weeks after that, then in 2-3 months after that until my beta-hCG is normal for 2 tests." c. "I should have my beta-hCG reevaluated at 6 weeks postpartum. I should follow up once a month for 6 months, then every 2-3 months months for 6 months until my beta-hCG is normal for 3 tests." d. "I should have my beta-hCG reevaluated at 6 weeks postpartum. I should follow up once a week for 6 months, then in 2-3 weeks for 6 months until my beta-hCG is normal for 3 tests."

c. "I should have my beta-hCG reevaluated at 6 weeks postpartum. I should follow up once a month for 6 months, then every 2-3 months months for 6 months until my beta-hCG is normal for 3 tests." Rationale: Follow-up is critical to detect changes suggestive of trophoblastic malignancy. Beta-hCG is repeated at 6 weeks postpartum. Follow-up protocol involves evaluation of serum beta-hCG levels monthly for 6 months, then every 2-3 months for 6 months until normal for 3 values. A persistent or rising beta-hCG level suggests continued gestational trophoblastic disease.

The nurse is providing dietary teaching to the mother of an infant with phenylketonuria (PKU). Which statement by the client indicates that the teaching was effective? a. "I should provide a special formula high in phenylalanine." b. "When I begin introducing solid foods, I should provide high-protein foods." c. "I should maintain the recommended diet to prevent cognitive impairment." d. "No amount of phenylalanine in my child's diet is safe."

c. "I should maintain the recommended diet to prevent cognitive impairment." Rationale: Infants with PKU receive a special formula LOW IN PHENYLALANINE. LOW-PROTEIN FOODS are introduced when solids are started. SMALL AMOUNTS OF PHENYLALANINE ARE ALLOWED because it is a necessary amino acid.

A nurse is providing discharge teaching to a client who just underwent a chorionic villus sampling (CVS). Which statement by the client indicates that the teaching was effective? a. "I can have sexual intercourse when I go home if I want to." b. "I will experience leaking of amniotic fluid for 2-3 days but that is normal." c. "I should rest for 24 hours and avoid exercise for the next several days." d. "If I have any spotting, I should return to the emergency department immediately."

c. "I should rest for 24 hours and avoid exercise for the next several days." Rationale: The client should avoid sexual intercourse for the next several days. The client should report leaking of amniotic fluid to the provider immediately. Spotting is normal for the first 2 days and usually resolves on its own.

A client who just received a vasectomy asks when he will be considered sterile. The nurse's best response is: a. "You are now considered sterile." b. "You will be sterile within a week." c. "It may take 3 months or more for complete sterilization." d. "You may not be sterile until after a year or more."

c. "It may take 3 months or more for complete sterilization." Rationale: The man should submit a semen specimen for analysis at 8 to 16 weeks to be sure that sperm are no longer present.

A client awaiting results of an important prenatal diagnostic study expresses concern and anxiety about waiting for the results. The nurse's best response is: a. "Don't worry. I'm sure the results are fine." b. "Don't worry. The results will be in before you know it." c. "Many couples find it difficult to wait for the results." d. "I wouldn't worry. There's nothing you can do about it either way."

c. "Many couples find it difficult to wait for the results." Rationale: A statement such as "many couples find it difficult to wait for the results" will often elicit free expression of the parents' feelings. The other responses are considered nontherapeutic and could end up hurting the nurse-client relationship.

The nurse is discussing risk factors for polycythemia with a client. Which statement by the client indicates a need for further teaching? a. "It is important that the umbilical cord is clamped immediately to prevent this." b. "My cigarette smoking could contribute to the risk of my infant developing polycythemia." c. "My hypotension could contribute to the risk of my infant developing polycythemia." d. "My diabetes could contribute to the risk of my infant developing polycythemia."

c. "My hypotension could contribute to the risk of my infant developing polycythemia." Rationale: Risk factors for polycythemia include postterm infants; large or small of gestational age; and infants of mothers who smoke, have HYPERTENSION, or have diabetes.

A newly licensed nurse is caring for a client who will have a biophysical profile (BPP) performed. The client asks the newly licensed nurse what characteristics will be assessed. Which statement by the newly licensed nurse requires the preceptor to intervene? a. "This can evaluate fetal movement." b. "This can evaluate fetal tone." c. "This can evaluate fetal weight." d. "This can evaluate amniotic fluid amount."

c. "This can evaluate fetal weight." Rationale: A BPP does not evaluate fetal weight. The other characteristic a BPP evaluates is fetal breathing movement.

A client is undergoing a nonstress test to evaluate fetal wellbeing. The fetal heart rate does not accelerate with movement and the client asks the nurse what this means. The nurse's best response is: a. "This is an ideal response and means that your baby is healthy." b. "This could indicate that your baby has alkalosis." c. "This could indicate that your baby has acidosis." d. "This likely means that your baby will be stillborn."

c. "This could indicate that your baby has acidosis." Rationale: An ideal response would be accelerations that match the fetal movements. This could indicate hypoxemia, which could cause acidosis, not alkalosis. This cannot tell the nurse whether the baby will be stillborn or not.

A nurse is providing teaching to a client about fetal doppler flow ultrasound. Which statement by the client indicates a need for further teaching? a. "This will assess the condition of my placenta." b. "This is a noninvasive procedure." c. "This will assess the volume of amniotic fluid." d. "This will look at the differences between systolic and diastolic blood flow velocities."

c. "This will assess the volume of amniotic fluid." Rationale: A fetal doppler flow ultrasound assesses the condition of the placenta, is a noninvasive procedure, and looks at the differences between peak-systolic and end-diastolic blood flow velocity. A biophysical profile assesses the volume of amniotic fluid.

A client who underwent a chorionic villus sampling (CVS) asks the nurse when to expect her results. The nurse's best response is: a. "You should receive your results within 24 hours." b. "You should receive your results within 2 to 3 days." c. "You should receive your results within 5 to 7 days." d. "You should receive your results within 1 to 2 weeks."

c. "You should receive your results within 5 to 7 days."

A client who underwent a nonstress test (NST) is scheduled for a contraction stress test (CST). She asks the nurse why she is undergoing this test if she already had an NST. The nurse's best response is: a. "These tests should always be done back to back to confirm fetal viability." b. "This test assesses your ability to contract and has nothing to do with the fetus." c. "Your fetus had a nonreactive NST and we want to make sure your fetus is viable." d. "This test determines when you are in true labor."

c. "Your fetus had a nonreactive NST and we want to make sure your fetus is viable." Rationale: A CST may be ordered if the findings of an NST are nonreactive.

The nurse is preparing to administer calcium gluconate to a client with magnesium toxicity. The nurse should administer ____ over ____ to reverse magnesium toxicity. a. 1 mg; 3 minutes b. 1 mg; 5 minutes c. 1 g; 3 minutes d. 1 g; 5 minutes

c. 1 g; 3 minutes Rationale: Magnesium toxicity can be reversed by IV administration of 1 g (10 mL of 10% solution) of calcium gluconate over 3 minutes.

A nurse is preparing to administer a maintenance dose of magnesium sulfate to a client at risk for preterm labor. What is the standard dose to infuse over 1 hour? a. 0.5-1 g b. 1-2 g c. 1-4 g d. 3-5 g

c. 1-4 g Rationale: The standard maintenance dose of IV magnesium sulfate for tocolysis is 1-4 g over 1 hour.

The nurse is assessing a cesarean client for postpartum hemorrhage. The nurse knows that postpartum hemorrhage after cesarean delivery is characterized by a cumulative blood loss of ≥ ____ mL. a. 500 b. 750 c. 1000 d. 1500

c. 1000 Rationale: Postpartum hemorrhage is defined as cumulative blood loss of ≥ 1000 mL or blood loss accompanied by signs and symptoms of hypovolemia within 24 hours following the birth process. During vaginal delivery, blood loss of ≥500 mL is categorized as postpartum hemorrhage.

The nurse assessing the nutritional status of a preterm infant receiving enteral feedings knows that this infant needs ___ kcal/kg/day. a. 70-115 b. 90-120 c. 105-130 d. 125-150

c. 105-130 Rationale: This amount varies according to activity, illness, and other factors that may affect caloric need. These infants need more protein, iron, calcium, and phosphorus.

The nurse assessing the weight gain of a preterm infant knows that the preterm infant should gain ____ a day. a. 5-10 g/kg/day b. 10-15 g/kg/day c. 15-20 g/kg/day d. 20-25 g/kg/day

c. 15-20 g/kg/day

A client is undergoing a nonstress test to evaluate fetal wellbeing. The nurse knows that accelerations should reach a peak of ____ bpm above baseline and last ____ seconds. a. 15; 10 b. 10; 15 c. 15; 15 d. 10; 10

c. 15; 15 Rationale: Accelerations should reach 15 bpm above baseline and last a minimum of 15 seconds but less than 2 minutes.

The nurse is assessing a client with postpartum depression. The nurse knows that postpartum depression typically presents within the first _____ and has the potential to last up to ______. a. 2 weeks; 3 months b. 6 weeks; 6 months c. 3 months; 1 year d. 6 months; 1 year

c. 3 months; 1 year Rationale: Postpartum depression differs from postpartum blues in that postpartum blues resolves within 2 weeks.

A nurse is assessing a client with uterine inversion who has an indwelling urinary catheter. The nurse knows that the urine output should be at least: a. 15 mL/h b. 25 mL/h c. 30 mL/h d. 50 mL/h

c. 30 mL/h Rationale: Urine output that is less than 30 mL/h could indicate an obstructed catheter or hypovolemia.

The nurse preparing to give an intermittent bolus feeding to a preterm infant knows that this feeding should be given over the course of ______. a. 5-10 minutes b. 20-30 minutes c. 30-60 minutes d. 1-2 hours

c. 30-60 minutes Rationale: Intermittent bolus feedings provide a more normal feeding pattern with periodic stimulation of gastric hormones and enzymes. They should be given slowly over 30 to 60 minutes.

The nurse is discussing breast cancer screening with a female client who is at the age that she should be receiving yearly screenings for breast cancer. What age is this client? a. 35 b. 40 c. 45 d. 50

c. 45 Rationale: Women should be able to start the screening as early as age 40 if desired and agreed upon by the health care providers regarding when to begin screening.

The nurse is assessing an infant for hyperbilirubinemia. The nurse knows that the infant has hyperbilirubinemia when the total serum bilirubin (TSB) level is greater than ____ mg/dL. a. 3-4 b. 4-5 c. 5-6 d. 6-7

c. 5-6 Rationale: When the TSB level is greater than 5-6 mg/dL, jaundice appears.

When using a diaphragm for contraception, the client should be instructed to: a. Avoid using a spermicide b. Insert it immediately before intercourse c. Be refitted if she gains or loses more than 10 pounds d. Leave it in place at least 24 hours following intercourse

c. Be refitted if she gains or loses more than 10 pounds Rationale: Weight changes affect vaginal size. If the client gains or loses 10 pounds, her diaphragm may not be the correct size and may not be effective. A spermicide can still be used with a diaphragm. The diaphragm can be inserted hours prior to sexual intercourse. The diaphragm should be removed after 6 hours.

The nurse is caring for a postpartum client with endometritis. Which position should this client be placed in? a. Trendelenburg b. reverse Trendelenburg c. Fowler's d. lateral

c. Fowler's Rationale: The woman with endometritis should be placed in a Fowler's position to promote drainage of lochia.

A 50-year-old client asks the nurse when she can start having breast cancer screenings every other year rather than every year. What is the nurse's best response? a. "You can start having them every other year now that you are 50 years old." b. "The recommendation has always been every other year. I'm not sure why you're receiving them every year." c. You can start having them every other year once you reach age 55." d. "You will need yearly screenings for the rest of your life."

c. You can start having them every other year once you reach age 55." Rationale: At age 55, women should have mammograms every other year, though women who want to keep having yearly mammograms should be able to do so.

A nurse is assessing a client in labor. The client informs the nurse that she had a cerclage placed earlier in the pregnancy. The nurse knows that a cerclage is: a. a mesh placed against the cervix b. an incision in the cervix c. a suture encircling the cervix d. a progesterone ring placed against the cervix

c. a suture encircling the cervix Rationale: A cerclage is a suture encircling the cervix placed earlier in a pregnancy to prevent premature cervical dilation in a client whose cervix dilates too early.

The experienced nurse is reviewing transmission of infection with a group of newly licensed nurses. The experienced nurse knows that the newly licensed nurses understand the review when they state that horizontal infection is acquired (Select all that apply): a. before birth b. during birth c. after birth

c. after birth Rationale: Horizontal infection occurs after birth, such as staphylococcal infections acquired from hospital staff members, contaminated equipment, or family members or visitors.

The nurse is caring for an infant with gonorrhea. What does the nurse know about gonorrhea (Select all that apply)? a. it may result in deafness if untreated b. the infant will be treated with IV antivirals c. all infants receive prophylactic treatment d. conjunctivitis may occur e. eye drainage will be red

c. all infants receive prophylactic treatment d. conjunctivitis may occur e. eye drainage will be red Rationale: May result in BLINDNESS if untreated. The infant will receive IV ANTIBIOTICS. All infants receive erythromycin eye ointment.

The nurse is assessing the temperature of an infant with hyperbilirubinemia. The nurse knows to assess the infant's ____ temperature every 2-4 hours. a. oral b. temporal c. axillary d. rectal

c. axillary Rationale: Assessing the infant's axillary temperature is the most appropriate at this time. An oral temperature could disturb the infant and is not as accurate and a rectal temperature is contraindicated due to risk of injury.

A nurse is providing teaching to a client diagnosed with gestational diabetes. The nurse explains that a glucose challenge test (GCT) is administered: a. between 12 and 20 weeks of gestation b. before 20 weeks of gestation c. between 24 and 28 weeks of gestation d. after 28 weeks of gestation

c. between 24 and 28 weeks of gestation Rationale: A GCT is administered between 24 and 28 weeks of gestation. Fasting is not necessary and the woman is not required to follow any pretest dietary instructions.

The nurse is caring for an infant with hypocalcemia who is receiving IV calcium gluconate. Which assessment finding leads the nurse to immediately stop the infusion? a. irritability b. apnea c. bradycardia d. jitteriness

c. bradycardia Rationale: IV calcium should be administered slowly and stopped immediately if bradycardia or dysrhythmia develops.

A nurse is assessing a client for magnesium sulfate toxicity. Which drug should be given if the client develops magnesium sulfate toxicity? a. vitamin K b. acetylcysteine c. calcium gluconate d. flumazenil

c. calcium gluconate Rationale: Vitamin K is the antidote for warfarin. Acetylcysteine is the antidote for acetaminophen. Flumazenil is the antidote for benzodiazepines.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding intrauterine devices (IUDs) (Select all that apply)? a. increased blood loss b. only effective for 1 year c. can be expelled without woman's knowledge d. can cause menorrhagia or infection e. expensive

c. can be expelled without woman's knowledge d. can cause menorrhagia or infection Rationale: IUDs may DECREASE DYSMENORRHEA AND BLOOD LOSS. An IUD is effective as long as 5-10 YEARS. An IUD has a LOW. LONG-TERM COST.

A client in labor is at risk for uterine rupture. The nurse knows that those at risk for uterine rupture include: a. obese clients b. clients receiving magnesium sulfate c. clients of high parity d. clients with oligohydramnios

c. clients of high parity Rationale: Obesity does not have any bearing on the strength of the uterine wall. Clients receiving oxytocin, rather than magnesium sulfate, are at higher risk for uterine rupture due to oxytocin's stimulating affects on uterine contractions. A client with oligohydramnios would not be at risk for uterine rupture as this indicates a decrease in amniotic fluid. Other clients at risk for uterine rupture include clients sustaining blunt abdominal trauma and women having intense contractions.

An infant is born with a congenital anomaly and the client is having trouble bonding with the infant. Which action by the nurse could facilitate bonding and attachment? a. hand the infant to the client b. explain to the client that she must bond with the infant c. communicate acceptance of the infant d. ask the client why she does not want her infant

c. communicate acceptance of the infant Rationale: The nurse should handle the newborn gently and present the infant as someone precious. It helps if the nurse can bring focus to the normal aspects of the infant's body, such as the eyes: "She has such beautiful eyes."

The nurse is assessing an infant with suspected intraventricular hemorrhage (IVH). The nurse assesses for which of the following manifestations (Select all that apply)? a. hypoglycemia b. tachycardia c. cyanosis d. drop in hematocrit e. tense muscle tone

c. cyanosis d. drop in hematocrit Rationale: Manifestations of IVH include lethargy, POOR MUSCLE TONE, BRADYCARDIA, deterioration of respiratory status with cyanosis or apnea, drop in hematocrit, acidosis, HYPERGLYCEMIA, tense fontanel, and seizures.

The nurse is assessing the laboratory values of a client with suspected disseminated intravascular coagulation (DIC). Which of the following laboratory values might the nurse expect with this diagnosis? a. shortened PTT and aPTT b. increased fibrinogen levels c. decreased platelet levels d. negative D-dimer serum assay

c. decreased platelet levels Rationale: PTT and aPTT may be prolonged, fibrinogen levels will be decreased, and a D-dimer serum assay will be positive. In a client without DIC, a D-dimer serum assay is negative.

A client with preeclampsia asks the nurse what the cure is for this condition. The nurse knows that the only cure for preeclampsia is: a. steroids b. ACE inhibitors c. delivery of the baby and placenta d. pitocin

c. delivery of the baby and placenta Rationale: Steroids are used to accelerate fetal lung maturity of the fetus must be delivered prior to 34 weeks of gestation. ACE inhibitors are contraindicated in the second and third trimesters because of the increased risk of fetal renal damage. Pitocin is used to induce labor but is not a cure for preeclampsia.

The nurse caring for an infant notes signs of necrotizing enterocolitis (NEC). What is the first action the nurse should take? a. notify the provider b. measure abdominal girth c. discontinue the feeding d. administer IV fluids

c. discontinue the feeding Rationale: Although all the choices are correct, the most important action at this time is to discontinue the feeding. Next, the nurse should notify the provider, measure abdominal girth, and administer IV fluids if ordered. The infant should be positioned on the side to minimize the effects of pressure on the diaphragm from the distended intestines.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following advantages will the nurse include regarding sterilization (Select all that apply)? a. protects against STDs b. reversal is easy c. ends concern about contraception d. can be performed with local anesthesia e. low long-term cost

c. ends concern about contraception d. can be performed with local anesthesia e. low long-term cost Rationale: Sterilization DOEES NOT PROTECT AGAINST STDs and reversal IS NOT ALWAYS SUCCESSFUL.

A nurse is caring for a client in the third stage of labor and suspected of uterine inversion. The nurse knows that uterine inversion may be caused by (Select all that apply): a. decreased intraabdominal pressure b. placental abruption c. fundal pressure during birth d. congenital weakness of the uterine wall e. excessive traction on the umbilical cord before placental detachment

c. fundal pressure during birth d. congenital weakness of the uterine wall e. excessive traction on the umbilical cord before placental detachment Rationale: Increased intraabdominal pressure, not decreased, could cause uterine inversion. An abnormally adherent placenta, not placental abruption, could cause uterine inversion. Other potential causes include fundal pressure on an incompletely contracted uterus after birth and fundal placental implantation.

The nurse caring for an infant with a diaphragmatic hernia knows that management includes (Select all that apply): a. placement of a nasal cannula b. positioning of the infant on the unaffected side c. gastric tube to decompress the stomach d. infant surgery to remove the infected portion of the intestines e. extracorporeal membrane oxygen (ECMO)

c. gastric tube to decompress the stomach e. extracorporeal membrane oxygen (ECMO) Rationale: Management of a diaphragmatic hernia includes fetal surgery; an ENDOTRACHEAL TUBE FOR MECHANICAL VENTILATION; a gastric tube for stomach decompression; surgery to REPLACE THE INTESTINES AND REPAIR THE DEFECT; ECMO or inhaled nitric oxide; positioning the infant ON THE AFFECTED SIDE to allow the unaffected lung to expand; and elevating the head to decrease pressure on the heart and lungs.

A client in labor is experiencing labor dystocia. Which of the following interventions could the nurse perform to help relieve this? a. request an epidural b. help her into a supine position c. help her into an upright position d. nothing can relieve this except time

c. help her into an upright position Rationale: An epidural could reduce the effectiveness of contractions. A supine position is contraindicated due to the risk of hypotension. Helping her into an upright position will make her more comfortable and allow gravity to help progress the labor. Other interventions include allowing her to stand or sit in a shower, administration of adequate IV or oral fluid, and/or oxytocin infusion.

A nurse is assessing a 33-year-old African American client weighing 210 lbs who is attempting to become pregnant. The nurse knows that this client is at a higher risk for ectopic pregnancy because of: a. her age b. her weight c. her history of Chlamydia d. her race

c. her history of Chlamydia Rationale: Neither age, weight, nor race have any bearing on the risk of ectopic pregnancy. A common factor for developing ectopic pregnancy is scarring of the fallopian tubes due to pelvic infection and inflammation, which could be caused by Chlamydia. Other risk factors include assisted reproduction, contraception such as intrauterine contraceptive devices and low-dose progesterone agents, delayed or premature ovulation, multiple induced abortions, and altered tubal motility.

The nurse is providing teaching to a 25-year-old Asian client weighing 180 lbs who may have a molar pregnancy (gestational trophoblastic disease). The nurse knows that which of the following may put the client at a higher risk for molar pregnancy? a. her age b. her weight c. her race

c. her race Rationale: The incidence of molar pregnancy is higher among Asian women. Other risk factors include women who have had one molar pregnancy, young age, and advanced age.

A client is in labor and her fetus is in a breech presentation. The nurse knows that this could be the result of: a. macrosomia b. spina bifida c. hydrocephalus d. occiput transverse position

c. hydrocephalus Rationale: Low birth weight, not macrosomia, could cause a breech presentation. Neither spina bifida nor the occiput transverse position have any bearing on the presentation of the fetus. Other reasons for breech presentation include fetal anomalies and complications secondary to placenta previa or previous cesarean birth.

A nurse is caring for a client with disseminated intravascular coagulation (DIC). What therapeutic management should the nurse expect to treat this condition? a. IV pitocin b. emergency cesarean c. identification and correction of the cause d. IV magnesium sulfate

c. identification and correction of the cause Rationale: The priority treatment of DIC is to correct the cause.

A nurse is assessing a client suspected of a missed spontaneous abortion. The nurse is concerned most about which complication? a. deep vein thrombosis b. emotional trauma c. infection d. weight gain

c. infection Rationale: Deep vein thrombosis is not a concern at this time. Emotional trauma is a consideration, but it is not the priority. Weight gain is not a concern at this time. Signs such as elevation in temperature, vaginal discharge with a foul odor, and abdominal pain indicate uterine infection. Another complication of missed spontaneous abortion is disseminated intravascular coagulation (DIC).

The nurse is assessing a client with endometritis for complications. Which of the following may be a complication of untreated endometritis? a. urinary tract infection b. gastrointestinal infection c. infection of the fallopian tubes d. uterine cancer

c. infection of the fallopian tubes Rationale: If infection spreads outside of the uterine cavity, it may cause salpingitis (infection of the fallopian tubes), oophoritis (infection of the ovaries), peritonitis, and pelvic thrombophlebitis.

The nurse assessing a female client notes that there is bloody discharge coming from her nipple. The nurse suspects that this may be due to: a. fibroadenoma b. fibrocystic breast changes c. intraductal papilloma d. ductal ectasia

c. intraductal papilloma Rationale: As the papilloma grows, it causes trauma and erosion within the ducts that result in serous or blood discharge from the nipple.

The nurse caring for an infant with retinopathy of prematurity (ROP) knows that the treatment of choice is: a. administer oxygen b. IV fluids c. laser surgery d. time

c. laser surgery Rationale: Laser surgery to destroy abnormal blood vessels is the current treatment of choice.

A nurse is caring for a client in precipitous labor. Which of the following interventions could the nurse perform to enhance fetal oxygenation? a. administer oxytocin b. administer oxygen via nasal cannula c. maintain adequate blood volume with non-additive IV fluids d. position the client supine

c. maintain adequate blood volume with non-additive IV fluids Rationale: If oxytocin is being used, it should be stopped. Although administering oxygen to the client is a possible intervention, it should only be administered via nonrebreather mask. Positioning the client supine will decrease fetal oxygenation and cause maternal hypotension.

The nurse is assessing a client whose fetus is at risk for asphyxia. Which assessment findings would lead the nurse to have this concern? a. maternal diabetes b. maternal hypotension c. maternal infection d. maternal exercise

c. maternal infection Rationale: Maternal risk factors for fetal asphyxia include HYPERTENSION, infection, and drug use.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding oral contraceptives (Select all that apply)? a. may cause acne b. may increase the risk of ectopic pregnancy c. may cause breakthrough bleeding d. increased risk of hypertension e. fertility usually takes 6 months to return

c. may cause breakthrough bleeding d. increased risk of hypertension Rationale: Oral contraceptives can IMPROVE ACNE AND DECREASE THE RISK OF ECTOPIC PREGNANCY. Fertility usually returns within 3 MONTHS.

Which of the following findings is the fetus at risk for if the client is at 42 weeks of gestation? a. intrauterine growth restriction b. hyperglycemia c. meconium aspiration d. polyhydramnios

c. meconium aspiration Rationale: The fetus that is postterm may experience their first meconium in utero, therefore this fetus is at an increased risk for meconium aspiration.

The nurse is discussing possible complications of ovulation induction. Which complication will the nurse include? a. trisomy 21 b. hypostimulation syndrome c. multiple births d. breakthrough bleeding

c. multiple births Rationale: Ovulation induction may increase the risk for multiple births because several ova may be released and fertilized. A serious complication is ovarian HYPERSTIMULATION syndrome, which involves marked ovarian enlargement with exudation of fluid and protein into the woman's peritoneal and pleural cavities.

The nurse is preparing to administer magnesium sulfate to a client with severe preeclampsia. Which finding would indicate that magnesium sulfate is inappropriate for this patient? a. blood pressure 165/115 mmHg b. systemic lupus erythematosus c. myasthenia gravis d. continuous headache

c. myasthenia gravis Rationale: Phenytoin may be used in cases in which magnesium sulfate is inappropriate, such as in cases of myasthenia gravis, compromised renal function, and significant pulmonary conditions.

The nurse is caring for a client with fibrocystic breast changes. The nurse knows that the most common symptom of fibrocystic breast changes is: a. swelling and redness b. painless nodules c. pain and tenderness d. dry, flaky areolas

c. pain and tenderness Rationale: The pain is often bilateral and most noticeable during the premenstrual phase of the normal cycle.

The nurse is explaining the difference between various cardiac defects. Which of the following is considered a left-to-right shunting defect? a. aortic stenosis b. Tetralogy of Fallot c. patent foramen ovale d. transposition of the great vessels

c. patent foramen ovale Rationale: Aortic stenosis is a defect with obstruction of blood outflow. Tetralogy of Fallot is a defect with decreased pulmonary blood flow. Transposition of the great vessels is a cyanotic defect with increased pulmonary blood flow.

A nurse is preparing a client for insertion of an intrauterine device (IUD). Which finding in the client's chart would lead the nurse to question the insertion of the IUD at this time? a. maternal age over 35 b. hypertension c. pelvic inflammatory disease d. smoker

c. pelvic inflammatory disease Rationale: The IUD should not be inserted if a woman has mucopurulent cervical discharge or a current infection such as chlamydia, gonorrhea, or pelvic inflammatory disease.

A nurse is reviewing the chart of a client scheduled to undergo a contraction stress test (CST). Which finding in the chart alerts the nurse that a CST is contraindicated? a. maternal hypertension b. gestational diabetes c. placenta previa d. primigravida

c. placenta previa Rationale: Maternal hypertension, gestational diabetes, and primigravida are not contraindications of CST. Other contraindications include preterm premature rupture of membranes, preterm labor, history of preterm delivery, previous classic cesarean section, and multiple gestations.

A client in labor is experiencing a high uterine resting tone and complains of continuous pain. The nurse knows that this could be a sign of: a. tachycardia b. late decelerations c. placental abruption d. placenta previa

c. placental abruption Rationale: High uterine resting tone is known as TACHYSYSTOLE.

The primary risk associated with an amniotomy is: a. maternal infection b. maternal hemorrhage c. prolapse of the umbilical cord d. separation of the placenta

c. prolapse of the umbilical cord Rationale: When the membranes are ruptured, the umbilical cord may come downward with the flow of amniotic fluid and become trapped in front of the presenting part. Infection is a risk of amniotomy, but not the primary concern. Maternal hemorrhage is not associated with amniotomy. This may occur if the uterus is overdistended before the amniotomy, but it is not the major concern.

A client is in the second stage of labor. As her baby's head is born, it displays the turtle sign. Which intervention should the nurse perform FIRST? a. prepare for emergency cesarean b. massage the fundus c. pull the client's knees up toward her shoulders d. prepare for forceps delivery

c. pull the client's knees up toward her shoulders Rationale: A cesarean is contraindicated at this time as the infant's head is already out of the birth canal. Fundal pressure should be avoided so that the fetus's shoulders are not pushed even harder against the symphysis. McRobert's maneuver is a nursing action that should be taken immediately by pulling the client's knees up as far toward her shoulders as possible. The delivery team should prepare for a surgical vaginal delivery, but this is not the first priority.

A client with preeclampsia is deemed at risk for severe preeclampsia. Which findings would suggest this diagnosis (Select all that apply)? a. blood pressure greater than 150/100 mmHg b. oliguria of less than 700 mL in 24 hours c. pulmonary edema c. thrombocytopenia e. serum creatinine greater than 1.1 mg/dL

c. pulmonary edema c. thrombocytopenia e. serum creatinine greater than 1.1 mg/dL Rationale: Severe preeclampsia is characterized by a blood pressure of 160/110 mmHg or higher. Oliguria of less than 500 mL in 24 hours is a sign of severe preeclampsia.

A client has been diagnosed with a ruptured ectopic pregnancy. Which finding is seen with this condition? a. no alteration in menses b. ultrasound indicating a fetus in the uterus c. report of severe shoulder pain d. serum glucose greater than expected

c. report of severe shoulder pain Rationale: Severe shoulder pain on the same side of the ectopic pregnancy is a common complaint as distention of the fallopian tube causes radiant pain to the shoulder.

The nurse is assessing an infant for signs of intrauterine drug exposure. Which signs should the nurse be aware of (Select all that apply)? a. diminished Moro reflex b. decreased muscle tone c. retractions d. hypotension e. tachycardia

c. retractions e. tachycardia Rationale: Signs of intrauterine drug exposure include irritability; jitteriness, tremors, seizures; muscular rigidity, INCREASED MUSCLE TONE; restless, excessive activity; EXAGGERATED MORO REFLEX; prolonged high-pitched cry; difficult to console; poor sleeping patterns; yawning; exaggerated rooting reflex; excessive sucking; uncoordinated sucking and swallowing ; frequent regurgitation or vomiting; diarrhea; weight loss; nasal stuffiness, sneezing; tachypnea, apnea; retractions; tachycardia; HYPERTENSION; fever; diaphoresis; excoriation; and mottling.

A nurse is providing teaching about spontaneous abortion to a client. The nurse explains that the most common cause of spontaneous abortion is: a. diabetes b. periodontal disease c. severe chromosomal abnormalities d. rubella

c. severe chromosomal abnormalities Rationale: Although diabetes, periodontal disease, and rubella may cause spontaneous abortion, they are not the most common causes. Other potential causes include syphilis, listeriosis, toxoplasmosis, brucellosis, cytomegalic virus, hypothyroidism, decreased progesterone, uterine septum, cervical incompetence, heavy alcohol consumption, and heavy smoking.

The nurse is providing contraceptive information for a 37-year-old woman. Which finding would the nurse see as a contraindication for oral contraceptives? a. overweight b. over 35 c. smoker d. African American

c. smoker Rationale: Women who smoke and are over the age of 35 years should not use estrogen-containing contraceptives.

A client has had an incomplete spontaneous abortion. The nurse's priority at this time is: a. assessment of fetal heart tones (FHTs) b. removal of remaining tissues in the uterus c. stabilizing the client's cardiovascular state d. providing emotional support

c. stabilizing the client's cardiovascular state Rationale: Assessing FHTs is unnecessary as the fetus is no longer living. Although remaining tissues should be removed from the uterus, this is not the priority at this time. The nurse should provide emotional support, but the priority at this time is the client's circulatory status.

The nurse is providing teaching to a postpartum client with mastitis about nonpharmacologic relief. Which measures should the nurse include? a. apply a cool compress to the area b. avoid breastfeeding on the affected side c. take a warm shower before breastfeeding d. apply a nursing pad with a plastic layer

c. take a warm shower before breastfeeding Rationale: The woman should apply a WARM, MOIST COMPRESS to apply heat. The woman should breastfeed on both sides and completely empty each breast to avoid an abscess. Taking a warm shower or placing hot packs on the breast before feeding may help with the discomfort. Nursing pads should not have a plastic layer.

A nurse receiving handoff report is informed that her client has Triple I. The nurse knows that this means that: a. the client will be giving birth to triplets b. the client's blood pressure is triple what it should be c. the client has intrauterine inflammation and infection d. the client will give birth to an infant with trisomy 21

c. the client has intrauterine inflammation and infection Rationale: Triple I is the preferred term to describe intrauterine inflammation or infection or both. Triple I is also known as chorioamnionitis, intra-amniotic infection or intra-uterine infection, but Triple I is the preferred term as it is more general and descriptive.

The client receiving magnesium sulfate has a serum magnesium level of 9 mg/dL. The nurse knows that this indicates: a. the client's serum magnesium is within the therapeutic range b. the client's serum magnesium is below the therapeutic range c. the client's serum magnesium is above the therapeutic range

c. the client's serum magnesium is above the therapeutic range Rationale: The therapeutic serum level for magnesium is 5-8 mg/dL.

The nurse is assessing a preterm infant to determine if he is ready for discharge. Which of the following may indicate a readiness for discharge? a. the family has at least 1 member who demonstrates the ability to feed and provide all needed care b. there is only minimal cardiorespiratory compromise during feeding c. the infant shows a sustained pattern of weight gain d. not all immunizations have been given but the parents state that they will bring their infant back to receive them

c. the infant shows a sustained pattern of weight gain Rationale: The family must have at least TWO MEMBERS who demonstrate the ability to feed and provide all needed care; there is NO CARDIORESPIRATORY COMPROMISE WITH FEEDING; and ALL IMMUNIZATIONS should be given.

A newly licensed nurse is providing care to a client who has uterine atony and suspected clots. Which action by the newly licensed nurse requires intervention by the preceptor? a. the newly licensed nurse massages the fundus b. the newly licensed nurse calls for help c. the newly licensed nurse attempts to express the clots d. the newly licensed nurse administers oxygen via nonrebreather mask

c. the newly licensed nurse attempts to express the clots Rationale: Clots are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. It is critical that the uterus is firmly contracted BEFORE attempting to express clots. Pushing on a uterus that is not contracted could invert the uterus and cause massage hemorrhage and rapid shock.

The newly licensed nurse is introducing the parents to the neonatal intensive care unit (NICU) setting. Which action by the newly licensed nurse requires the preceptor to intervene? a. the newly licensed nurse offers realistic encouragement based on the infant's condition b. the newly licensed nurse introduces the parents to their infant's nurse c. the newly licensed nurse brings them to the NICU and leaves to give them privacy d. the newly licensed nurse gives the parents printed information about the NICU so that they can take it home to read later

c. the newly licensed nurse brings them to the NICU and leaves to give them privacy Rationale: The newly licensed nurse should stay with the parents during their first visit. Having a familiar person nearby will help them feel more comfortable while they adjust to this unfamiliar environment.

A newly licensed nurse is assessing a client at term with placenta previa. Which action by the newly licensed nurse requires the preceptor to intervene? a. the newly licensed nurse monitors the fetal heart rate b. the newly licensed nurse keeps the family informed of the condition of the client and fetus c. the newly licensed nurse performs a sterile vaginal exam to assess dilation d. the newly licensed nurse prepares to start an IV

c. the newly licensed nurse performs a sterile vaginal exam to assess dilation Rationale: Digital examination of the cervical os can cause additional placental separation or tear the placenta, causing severe hemorrhage and extreme risk to the fetus. Other interventions the nurse could perform include administration of preoperative antibiotics and anesthesia, foley catheter insertion, preparation for cesarean birth if necessary, and notification of neonatology in the event that neonatal resuscitation is necessary.

The nurse is assessing a client who is Rh-negative. The nurse knows that most exposure of maternal to fetal blood occurs during: a. the first trimester b. the first stage of labor c. the third stage of labor d. the third trimester

c. the third stage of labor Rationale: Most exposure of maternal blood to fetal blood occurs during the third stage of labor, when active exchange of fetal and maternal blood may occur from damaged placental vessels.

A client is scheduled for a percutaneous umbilical blood sampling (PUBS). The nurse knows that this requires fetal blood to be drawn from: a. the umbilical arteries b. the ductus venosus c. the umbilical vein d. the placenta

c. the umbilical vein Rationale: Drawing from the umbilical arteries could result in hemorrhage, drawing from the placenta would not provide an accurate measurement, and drawing from the ductus venosus is contraindicated due to the risk of fetal injury.

The nurse is caring for an infant with short bowel syndrome (SBS). The nurse knows that the primary method of feeding will be: a. nasogastric (NG) tube b. jejunostomy (J) tube c. total parenteral nutrition (TPN) d. breastfeeding

c. total parenteral nutrition Rationale: TPN is begun as the primary source of nutrition. It is formulated to meet the infant's nutritional needs as well as promote weight gain and growth.

A nurse assessing a client in the third stage of labor notes a depression in the fundal area. The nurse knows that this could be indicative of: a. postpartum hemorrhage b. uterine rupture c. uterine inversion d. placenta previa

c. uterine inversion Rationale: The fundus would be boggy in the case of postpartum hemorrhage or uterine rupture. The fundus is unaffected by placenta previa.

A nurse is providing teaching to a client at her first prenatal visit. The nurse explains to the client that the first sign of a threatened spontaneous abortion is: a. uterine cramping b. pelvic pressure c. vaginal bleeding d. persistent backache

c. vaginal bleeding Rationale: Although the client with a threatened spontaneous abortion may experience uterine cramping, pelvic pressure, and persistent backache, these are not the typical first signs of a threatened spontaneous abortion and are more likely to be associated with loss of pregnancy.

The nurse is caring for a client suspected of having gestational trophoblastic disease. The nurse knows to look for the following manifestations (Select all that apply): a. lower levels of beta-hCG than expected for gestation b. a uterus that is smaller than expected for gestational age c. vaginal bleeding, which varies from dark-brown spotting to profuse hemorrhage d. excessive nausea and vomiting e. early development of preeclampsia before 24 weeks gestation in an otherwise normal pregnancy

c. vaginal bleeding, which varies from dark-brown spotting to profuse hemorrhage d. excessive nausea and vomiting e. early development of preeclampsia before 24 weeks gestation in an otherwise normal pregnancy Rationale: Levels of beta-hCG will be increased, not decreased. The uterus will be larger than expected, not smaller.

The nurse is providing home care teaching about preventing infection to a client who experienced a spontaneous abortion. Which statement by the client indicates a need for further teaching? a. "If I experience vaginal bleeding, I should avoid using tampons." b. "My risk for infection will be highest during the next 3 days." c. "I need to practice careful handwashing before and after cleaning my perineum." d. "I can have sexual intercourse when I get home today."

d. "I can have sexual intercourse when I get home today." Rationale: Perineal pads should be applied in a front-to-back fashion instead of tampons until vaginal bleeding has subsided. The woman should consult with her provider about safe timing for resuming intercourse.

A client is in labor and recently used heroin. The client is angry and being verbally abusive to the nurse. The best response by the nurse is: a. "If you continue to talk to me that way, I'll have to restrain you." b. "Please don't take that tone with me. I'm only trying to help." c. "Why are you being so mean? What did I do wrong?" d. "I know you are in pain and are frightened. I'll do everything I can to make you comfortable."

d. "I know you are in pain and are frightened. I'll do everything I can to make you comfortable." Rationale: The other responses are nontherapeutic because the nurse's tone is accusatory and defensive.

A nurse is providing teaching to a client who has just had a tubal ligation performed. Which statement by the client indicates an understanding of the teaching? a. "I will be given opioids for pain." b. "I can begin intercourse as soon as I return home." c. "I should avoid heavy lifting for 1 month." d. "I should avoid strenuous exercise for 1 week."

d. "I should avoid strenuous exercise for 1 week." Rationale: MILD ANALGESICS may be needed for pain. the woman avoids intercourse and lifting heavy objects for 1 WEEK.

The nurse is providing teaching to a client about breast pump use. Which statement by the client indicates an understanding of the teaching? a. "I should pump at least 3 times a day for 10 minutes per pumping session or a total of at least 30 minutes per day." b. "I should pump at least 5 times a day for 10 minutes per pumping session or a total of at least 50 minutes per day." c. "I should pump at least 3 times a day for 20 minutes per pumping session or a total of at least 60 minutes per day." d. "I should pump at least 5 times a day for 20 minutes per pumping session or a total of at least 100 minutes per day."

d. "I should pump at least 5 times a day for 20 minutes per pumping session or a total of at least 100 minutes per day." Rationale: The mother who plans to breastfeed needs help with maintaining lactation until the infant is mature enough to nurse. Help her begin to use a breast pump as soon as possible after birth and instruct her to pump at least 5 times a day for 20 minutes per pumping session or a total of at least 100 minutes per day.

A client is in her 31st week of gestation and is scheduled for antepartum fetal surveillance. She asks the nurse why this test is being performed so late in her pregnancy. The nurse's best response is: a. "This really should have been performed in your first trimester." b. "There was no need to perform this test before now." c. "This test could pose a serious risk to the fetus before 30 weeks of gestation." d. "This test should not be initiated until the gestational age is sufficient to expect infant survival if early delivery becomes necessary."

d. "This test should not be initiated until the gestational age is sufficient to expect infant survival if early delivery becomes necessary." Rationale: In some cases, results of antepartum fetal surveillance indicate that preterm delivery should be performed in order to ensure the infant's survival and therefore should not be performed until 24-32 weeks of gestation to ensure postpartum survival.

The nurse knows that an amniocentesis is performed between _____ weeks of gestation. a. 10-12 b. 10-15 c. 12-16 d. 15-20

d. 15-20 Rationale: An amniocentesis must be performed before 20 weeks in case the parents decide to abort the fetus based on results. An amniocentesis performed before 15 weeks could result in a false negative.

The nurse is caring for a postpartum client with endometritis. The nurse knows to assess this client's vital signs every ____ while fever is present and every ____ afterward. a. 15 minutes; 1 hour b. 30 minutes; 2 hours c. 1 hour; 3 hours d. 2 hours; 4 hours

d. 2 hours; 4 hours Rationale: The nurse should monitor the woman's response to treatment, and note signs of improvement or of continued infection (nausea and vomiting, abdominal distention, absent bowel sounds, and severe abdominal pain).

A client is having an amniocentesis performed. The nurse knows that _______ mL of fluid should be removed for examination. a. 1-2 b. 5 c. 10 d. 20

d. 20 Rationale: 1-2 mL of fluid is discarded before 20 mL is removed for examination.

The common definition of bronchopulmonary dysplasia (BPD) is when an infant requires oxygen ____ after birth. a. 48 hours b. 72 hours c. 7 days d. 28 days

d. 28 days Rationale: The diagnostic criteria for BPD include gestational age, the length of time on oxygen, and the amount of oxygen needed. The common definition of BPD is when an infant requires oxygen 28 days after birth.

A nurse is caring for a client with gestational diabetes (GDM). The nurse knows that the gold standard for diagnosing GDM is: a. glucose challenge test (GCT) b. hemoglobin A1c (hbA1c) c. urinalysis (UA) d. 3-hour oral glucose tolerance test (OGTT)

d. 3-hour oral glucose tolerance test (OGTT) Rationale: The 3-hour OGTT is the gold standard for diagnosing diabetes, but is a more complex test than the GCT.

The nurse is preparing to insert an indwelling gavage feeding catheter for a preterm infant. The nurse knows that this catheter can stay in the place for up to ____ a. 24 hours b. 72 hours c. 7 days d. 30 days

d. 30 days Rationale: For intermittent (bolus) feedings, a small, soft catheter is inserted through the nose or mouth every 2-3 hours. For continuous feedings, an indwelling catheter is inserted through the nose or mouth and can stay in place for up to 30 days.

Adjuvant treatment with tamoxifen may be recommended for clients with breast cancer if the tumor is: a. Less than 5 cm in size b. Located in the upper outer quadrant only c. Contained only in the breast d. Estrogen receptive

d. Estrogen receptive Rationale: Tamoxifen is antiestrogen therapy for tumors stimulated by estrogen. Tamoxifen is used depending on age, stage, and hormone receptor status, not size. Location of the cancer does not determine the usefulness of tamoxifen. Stage of the cancer is a consideration, but more important is its sensitivity to estrogen.

A nurse is assessing a client that is at 24 weeks of gestation. Her blood pressure is 145/97 mmHg and her urine is positive for protein, but her serum liver enzymes and platelets are normal. The nurse knows that this client will likely be diagnosed with: a. gestational hypertension b. superimposed hypertension c. HELLP Syndrome d. Preeclampsia

d. Preeclampsia Rationale: Gestational hypertension is characterized by a blood pressure ≥140/90 without proteinuria. Superimposed hypertension is not a known condition. HELLP syndrome is a subset of severe preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelets.

The nurse is caring for an infant with pathologic jaundice. The nurse knows that the most common cause of pathologic jaundice is: a. maternal diabetes b. maternal hypertension c. meconium aspiration syndrome d. Rh-incompatibility

d. Rh-incompatibility Rationale: The best known cause of pathologic jaundice is Rh-incompatibility, in which the Rh-negative mother forms antibodies when blood from an Rh-positive fetus enters her circulation. Other causes include infection, hypothyroidism, polycythemia, and biliary atresia.

A client has just given birth to an infant with severe meconium aspiration syndrome (MAS). The infant's heart rate is below 100 bpm and the labor and delivery team have suctioned and dried and stimulated the infant, but the condition is not improving. What does the nurse anticipate as the next intervention? a. place the infant skin-to-skin with the mother b. place the infant in a radiant warmer c. begin performing CPR d. administer positive pressure ventilation

d. administer positive pressure ventilation Rationale: If the infant is not breathing or has a heart rate below 100 bpm after opening the airway, suctioning, and being dried and stimulated, positive pressure ventilation is required.

The nurse is preparing an infant with hyperbilirubinemia for an exchange transfusion after phototherapy has been deemed unsuccessful. The client asks about complications. Which of the following are potential complications of an exchange transfusion (Select all that apply)? a. hypercalcemia b. hypokalemia c. hyperglycemia d. cardiac dysrhythmias e. necrotizing enterocolitis

d. cardiac dysrhythmias e. necrotizing enterocolitis Rationale: Complications that may occur from exchange transfusions include HYPOCALCEMIA, hypomagnesemia, HYPOGLYCEMIA, HYPERKALEMIA, infection, cardiac dysrhythmias, necrotizing enterocolitis, bleeding, thrombosis, thrombocytopenia, and air embolism.

A client who has preeclampsia does not have proteinuria. Which other finding might indicate that the client is preeclamptic (Select all that apply)? a. thrombocythemia b. peripheral edema c. decreased serum creatinine d. elevated serum liver enzymes e. cerebral or visual symptoms

d. elevated serum liver enzymes e. cerebral or visual symptoms Rationale: The client may be diagnosed with preeclampsia if she has thrombocytopenia, pulmonary edema, and increased serum creatinine.

The nurse knows that fetal problems associated with dysfunctional labor are related to (Select all that apply): a. maternal exhaustion b. primigravida c. multigravida d. fetal anomalies e. fetal size

d. fetal anomalies e. fetal size Rationale: Maternal exhaustion is a problem of powers, not passenger. The number of pregnancies a woman has does not have any bearing on the function of the labor.

The nurse caring for the client with HELLP syndrome is preparing to administer a medication to control her blood pressure. The nurse can administer one of the following medications: a. captopril or lisinopril b. magnesium sulfate or calcium gluconate c. phenytoin or diazepam d. hydralazine or labetalol

d. hydralazine or labetalol Rationale: Treatment of HELLP syndrome includes magnesium sulfate to control seizures and hydralazine or labetalol to control blood pressure.

A client just delivered a baby weighing 8 lb 15 oz. The nurse knows that this newborn is considered: a. microsomic b. normal for gestational age c. small for gestational age d. macrosomic

d. macrosomic Rationale: Microsomic is not a real term. A newborn is considered normal for gestational age if it is between 5 lb 8 oz and 8 lb 12 oz. A newborn is considered small for gestational age if it is less than 5 lb 8 oz.

The nurse is discussing advantages and disadvantages of the most common contraceptive methods. Which of the following disadvantages will the nurse include regarding the vaginal contraceptive ring (NuvaRing) (Select all that apply)? a. requires a fitting b. can only stay in place for 3 days c. side effects include deep vein thrombosis d. must remember when to remove and insert e. no protection against STDs

d. must remember when to remove and insert e. no protection against STDs Rationale: NO FITTING REQUIRED. Can stay in place for 3 WEEKS AT A TIME. Side effects include EXPULSION AND VAGINAL DISCOMFORT OR DISCHARGE.

Which diagnostic test evaluates the effect of fetal movement on fetal heart activity? a. contraction stress test (CST) b. sonography c. biophysical profile d. nonstress test (NST)

d. nonstress test (NST) Rationale: An NST evaluates the ability of the fetal heart to accelerate either spontaneously or in association with fetal movement. CST evaluates the fetal reaction to contractions. Sonographic examinations visualize the fetus and are done for various reasons. The biophysical profile evaluates fetal status using many variables.

A nurse is assessing a client suspected of having a prolapsed umbilical cord. The cord is compressed between the fetal presenting part and the pelvis but cannot be seen or felt during vaginal examination. The nurse knows that this is known as a (an): a. variable prolapse b. late prolapse c. complete prolapse d. occult prolapse

d. occult prolapse Rationale: A complete prolapse occurs when the cord can be seen protruding from the vagina.

A nurse is reviewing the chart of a client with hyperemesis gravidarum (HEG). The nurse knows that this is a condition characterized by: a. excessive nausea and vomiting that resolves after the first trimester b. projectile vomiting without nausea c. nausea without vomiting that occurs throughout pregnancy d. persistent, uncontrollable vomiting that continues throughout the pregnancy

d. persistent, uncontrollable vomiting that continues throughout the pregnancy Rationale: HEG is characterized by persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy. HEG is not self-limiting and can have serious consequences, unlike morning sickness.

Glucose metabolism is profoundly affected during pregnancy because: a. pancreatic function in the islets of Langerhaus is affected by pregnancy b. a pregnant woman uses glucose at a more rapid rate than a nonpregnant woman c. a pregnant woman increases her dietary intake significantly d. placental hormones are antagonistic to insulin, resulting in insulin resistance

d. placental hormones are antagonistic to insulin, resulting in insulin resistance Rationale: Placental hormones, estrogen, progesterone, and human placental lactogen (HPL), create insulin resistance. Insulin also is broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.

A nurse has determined that the client has uterine inversion. The nurse knows that the physician will likely: a. perform an amniotomy b. order magnesium sulfate c. massage the fundus d. replace the uterus through the vagina

d. replace the uterus through the vagina Rationale: An amniotomy is unnecessary as the client has already given birth. Magnesium sulfate is unnecessary as it decreases uterine contractions during preterm labor. Massaging the fundus is contraindicated as fundal pressure after birth is a potential cause of uterine inversion.

The nurse is assessing the glucose level an infant of a diabetic mother (IDM) using a bedside glucometer. The infant's glucose level is 38 mg/dL. What should the nurse do next? a. document the glucose level in the chart b. administer insulin to reduce the glucose level c. administer IV glucose to increase the glucose level d. report the glucose level and verify it by laboratory analysis

d. report the glucose level and verify it by laboratory analysis Rationale: Glucose levels of less than 40-45 mg/dL measured with a bedside glucometer should be reported and verified by laboratory analysis. Infants should be fed early to prevent hypoglycemia and immediately if low blood glucose occurs to prevent further decreases.

What action should be initiated to limit hypovolemic shock when uterine inversion occurs? a. administer oxygen at 3 L/minute by nasal cannula b. administer an oxytocin drug by intravenous push c. monitor the fetal heart rate every 5 minutes d. restore circulating blood volume by increasing the intravenous infusion rate

d. restore circulating blood volume by increasing the intravenous infusion rate Rationale: Intravenous fluids are necessary to replace the lost blood volume that occurs in uterine inversion. Administering oxygen will not prevent hypovolemic shock and oxygen should only be administered via nonrebreather mask. Oxytocin drugs should not be given until the uterus is repositioned. A uterine inversion occurs during the third stage of labor.

A client who is at 17 weeks of gestation is being assessed during her prenatal visit. She states that her belly has shrunk and her breasts are no longer tender. The nurse suspects that: a. she is progressing through the pregnancy normally b. she is not eating enough c. she has been exercising too vigorously d. she has had a missed spontaneous abortion

d. she has had a missed spontaneous abortion Rationale: A missed spontaneous abortion occurs when the fetus dies but is retained in the uterus. Symptoms of pregnancy disappear and the uterus stops growing and decreases in size as the amniotic fluid is absorbed back into the maternal circulation and the fetal tissue degrades.

The client with persistent gestational trophoblastic disease asks the nurse about potential metastasis. The nurse explains that it may undergo malignant change and metastasize to: a. the bone b. the lymph nodes c. the skin d. the lungs

d. the lungs Rationale: Gestational trophoblastic disease may metastasize to sites such as the lungs, vagina, liver, and brain.

The nurse is explaining the difference between various cardiac defects. Which of the following is considered a cyanotic defect? a. patent ductus arteriosus b. ventricular septal defect c. pulmonary stenosis d. transposition of the great vessels

d. transposition of the great vessels Rationale: Patent ductus arteriosus is an acyanotic defect. Ventricular septal defect is a left-to-right shunting defect. Pulmonary stenosis is a defect with obstruction to blood outflow.

The nurse is explaining retrograde ejaculation to a client. What should the nurse say that retrograde ejaculation is? a. when the semen is not expelled as quickly as desired b. when the man ejaculates too quickly c. when the man cannot ejaculate d. when the semen is released backward into the bladder

d. when the semen is released backward into the bladder Rationale: Retrograde ejaculation is the release of semen backward into the bladder rather than forward through the tip of the penis.