NUP 410 Week 8 (Chapters 20, 21, 22, and 47) NCLEX STYLE

Answer: 1, 2, 3 Explanation: 1. Cramping is a common reaction to the medication. 2. Uterine irritability is a common reaction to the medication. 3. Membrane rupture is a sign of labor and not a reaction to the medication. 4. Leakage of the gel is a common reaction that does not need to be reported. 5. Strong regular contractions are a sign of labor and not a reaction to the medication.

A client at 40 weeks' gestation is prescribed dinoprostone (Cervidil) for cervical ripening. What should the nurse include when teaching the client about this medication? Select all that apply. 1. Cramping can occur. 2. Uterine irritability is expected. 3. Membrane rupture is a sign of labor. 4. Leakage of the gel should be reported. 5. Strong regular contractions are expected.

Answer: 2, 5 Explanation: 1. A previous cesarean birth is a contraindication for a version. 2. A podalic version is used only with the second fetus during a vaginal twin birth and only if the twin does not descend readily. 3. Premature rupture of membranes is a contraindication for a version. 4. Presence of third-trimester bleeding is a contraindication for a version. 5. A podalic version is used only with the second fetus during a vaginal twin birth and only if the heart rate is nonreassuring.

A client in the midst of labor and delivery of twins is being considered for a podalic version. What should the nurse assess in order for this version to be considered? Select all that apply. 1. Previous cesarean birth 2. Second fetus does not descend 3. Premature rupture of membranes 4. Presence of third-trimester bleeding 5. Second fetus heart rate nonreassuring

Answer: 2 Explanation: 1. Amniotomy is used to induce labor; however, a vaginal delivery is unlikely. 2. Cesarean section is the most likely course of action. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed. 3. Nipple stimulation is used to induce labor; however, a vaginal delivery is unlikely. 4.Oxytocin is used to induce labor; however, a vaginal delivery is unlikely.

A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate? 1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4.Oxytocin administration

Answer: 1, 2, 3 Explanation: 1. The exact cause of hydramnios is unknown. 2. Hydramnios can cause maternal shortness of breath and edema. 3. Hydramnios is associated with maternal diabetes. 4. Hydramnios is not associated with large-for-gestational-age infants. 5.Renal malformation or dysfunction and postmaturity can cause oligohydramnios.

A pregnant client diagnosed with hydramnios asks for more information about this health problem. What should the nurse include in this teaching? Select all that apply. 1. The exact cause is unknown. 2. It can cause shortness of breath and edema. 3. It can be associated with maternal diabetes. 4. It occurs in large-for-gestational-age infants. 5.It is associated with renal malformation or dysfunction.

Answer: 1 Explanation: 1. Early signs of digoxin (Lanoxin) toxicity are bradycardia and arrhythmias 2. Digoxin (Lanoxin) toxicity does not cause tinnitus (ringing in the ears). 3. Digoxin (Lanoxin) toxicity does not cause ataxia (unsteady gait). 4.Digoxin (Lanoxin) toxicity does not cause hypotension (low blood pressure).

A toddler is prescribed digoxin (Lanoxin) for cardiac failure. Which should the nurse instruct the toddler's parents to monitor for as a manifestation associated with digoxin toxicity? 1. Bradycardia 2. Tinnitus 3. Ataxia 4.Hypotension

Answer: 2 Explanation: 1. Low-grade fever is not a normal finding in a child with a mild cyanotic heart defect and could be a sign of infective endocarditis. 2. A child with a mild cyanotic heart defect should be treated as normally as possible without activity adjustment. 3. Any child with a heart defect could develop congestive heart failure. 4.Fevers are treated with antipyretics so that dehydration is avoided.

An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment? 1. "Your child will have a low-grade fever until the defect is repaired." 2. "It is important for your child to maintain normal activity." 3. "Your child is not at risk for congestive heart failure." 4."It is important to avoid antipyretics for the treatment of fever."

Answer: 3 Explanation: 1. Respirations are difficult to monitor during active periods, making this an unrealistic goal. 2. Feedings should be small-volume, high-calorie. 3. It is important to allow for uninterrupted sleep to decrease metabolic demands on the heart. 4.Fluids should be restricted to high-calorie and low-volume in order to avoid overloading the lungs with fluid.

A 2-month-old infant with a congenital heart defect is admitted to the pediatric intensive care unit with congestive heart failure. Which intervention should the nurse include in the infant's plan of care? 1. Monitor respirations during active periods. 2. Give larger feedings less often to conserve energy. 3. Organize activities to allow for uninterrupted sleep. 4.Force fluids appropriate for age.

Answer: 1 Explanation: 1. The child is not contagious so contact isolation is not appropriate. 2. Aspirin is used as an anti-inflammatory and is prescribed around the clock. This is appropriate. 3. This examination will be used as a baseline to compare against as the child recovers to assist in monitoring for cardiac lesions. 4.The child will need close monitoring during the early period of the disease.

A child is admitted to the pediatric medical unit with a diagnosis of Kawasaki disease. Which provider prescription should the nurse question? 1. Contact isolation 2. Oral aspirin every 8 hours 3. Echocardiogram 4.Vital signs every 4 hours

Answer: 4 Explanation: 1. Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or prn. 2. Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor. 3. Vaginal examinations are contraindicated because the examination can stimulate bleeding. 4.Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety.

A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client? 1. Assessing blood pressure every 2 hours 2. Evaluating the fetal heart rate with an internal monitor 3. Limiting vaginal examinations to only one per 24-hour period 4.Monitoring for blood loss, pain, and uterine contractibility

Answer: 1 Explanation: 1. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the client with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop. 2. Gestational diabetes can lead to polyhydramnios but does not cause oligohydramnios. 3. The risk of fetal demise is increased with oligohydramnios. Labor is usually induced when the client reaches term pregnancy to prevent fetal demise. 4.Oligohydramnios occurs in 1% to 3% of pregnancies. It rarely recurs in subsequent pregnancies.

A client at 38 weeks' gestation is diagnosed with oligohydramnios. Which statement indicates that teaching has been effective? 1. "When I go into labor, I should come to the hospital right away." 2. "My gestational diabetes may have caused this problem to develop." 3. "Women with this condition usually go into labor after their due date." 4."This problem is common and will likely occur with my next pregnancy."

Answer: 4 Explanation: 1. Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. 2. Dinoprostone (Cervidil) is used to facilitate cervical ripening, which might be premature since the fetal position needs to be evaluated before proceeding with the induction. 3. EFM will not provide enough information regarding the position of the fetus. 4.Because malpresentation, such as breech, is a relative contraindication to induction of labor, the client will require additional evaluation by the healthcare provider before proceeding.

A client at 39 weeks' gestation being prepared for labor induction feels as though the baby has "flipped." What action should the nurse take? 1. Evaluate fetal maturity. 2. Administer dinoprostone (Cervidil) vaginal gel. 3. Implement continuous electronic fetal monitoring (EFM). 4.Notify the healthcare provider that the client feels as though the baby has changed position.

Answer: 4 Explanation: 1. Oxygen will not hurt, but it is not the priority. 2. Terbutaline would not be recommended. The contraction pattern is incoordinate, but they need to be enhanced, not stopped. 3. An epidural will not change the incoordinate contraction pattern. 4.The client is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions.

A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. What action should the nurse make a priority at this time? 1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4.Begin oxytocin after assessing for cephalopelvic disproportion (CPD).

Answer: 1, 2, 3, 5 Explanation: 1. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include position. 2. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include effacement. 3. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include consistency. 4. A prelabor scoring system was developed that is helpful to predict the potential success of induction. The fetal heart rate is not a component that is evaluated. 5. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include cervical dilatation.

A client at 40 weeks' gestation is being considered for cervical ripening. Which criteria should the nurse use to determine the client's success for induction? Select all that apply. 1. Position 2. Effacement 3. Consistency 4. Fetal heart rate 5. Cervical dilatation

Answer: 1, 2, 4, 5 Explanation: 1. Because of neck compression the trachea and larynx may be compressed, compromising this newborn's airway. 2. Because of the presentation, bruising may occur to the face. 3. Meconium aspiration is not associated with this type of delivery. 4. Because of the presentation, facial edema may occur. 5. Because of cerebral and neck compression, neck and head range of motion may be compromised.

A client delivered a fetus with the following head shape: On what should the nurse focus when assessing this newborn? Select all that apply. 1. Airway 2. Amount of bruising 3. Meconium aspiration 4. Degree of facial edema 5. Neck and head movement

Answer: 2 Explanation: 1. Use of the vacuum extraction for eight contractions is too many and can create damage to the fetal head. If fetal descent does not occur with the first two pulls, the procedure should be discontinued, and cesarean birth should take place. 2. Caput in the shape of the vacuum cup is usually present immediately after birth and resolves in 2 to 3 days. 3. This is a cephalohematoma and is a complication of vacuum extraction birth. 4.Negative pressure is suction, which is needed to use the vacuum extractor to facilitate birth.

A client experiencing a difficult labor has a vacuum extraction birth. What is expected with this type of delivery? 1. The head is delivered after eight pulls during contractions. 2. The location of the vacuum is apparent on the fetal scalp after birth. 3. A bruise is present on the occiput that does not cross the suture line. 4.Positive pressure is applied by the vacuum extraction during contractions.

Answer: 3 Explanation: 1. The vacuum extractor might leave a bruise on the scalp where the device is placed. 2. The vacuum extractor is applied to the scalp for up to 10 minutes total. 3. Vacuum extraction is an assistive delivery, and the client must continue with pushing efforts to accomplish the birth. 4.The vacuum extractor is a small cup-shaped device that is applied to the scalp.

A client experiencing a difficult labor is going to have vacuum extraction to facilitate delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "The baby's head might have a bruise from the vacuum cup." 2. "The vacuum will be applied for a total of 10 minutes or less." 3. "I can stop pushing and just rest if the vacuum extractor is used." 4."A small cup will be put onto the baby's head, and a gentle suction will be applied."

Answer: 1, 2, 4, 5 Explanation: 1. If the client has been under general anesthesia, she should be positioned on her side to facilitate drainage of secretions. 2. It is important to observe the urine for a bloody tinge, which could mean surgical trauma to the bladder. 3. Assessment of the level of anesthesia is performed for a client recovering from spinal anesthesia. 4. After a cesarean section, evaluate the dressing and perineal pad every 15 minutes for at least 1 hour. 5. The fundus should be gently palpated to determine whether it is remaining firm.

A client is recovering from general anesthesia after an emergency cesarean birth. What actions should the nurse take when providing care to this client? Select all that apply. 1. Position on the left side. 2. Observe urine for hematuria. 3. Assess level of anesthesia every 15 minutes. 4. Evaluate perineal pad every 15 minutes for 1 hour. 5. Gently palpate the fundus with vital signs assessment.

Answer: 3 Explanation: 1. The perinatal mortality rate for monoamniotic siblings is 10% to 32%. 2. Twins are more likely to have complications than are singleton births. 3. This is true. Spontaneously conceived twins are less likely to develop complications. 4.Primiparous women with twin pregnancies are more likely to develop complications.

A client pregnant with twins asks if the pregnancy will be uncomplicated. How should the nurse respond to this client? 1. "The perinatal mortality rate for monoamniotic siblings is 50%." 2. "Twins are less likely to have complications than are singleton births." 3. "Spontaneously conceived twins are less likely to develop complications." 4."Primiparous women pregnant with twins are less likely to develop complications."

Answer: 3 Explanation: 1. Providing an additional ice pack before 20 minutes have passed would increase the perineal edema. 2. More than one ice pack must be used in order to apply ice for 20 minutes on, followed by 20 minutes off. 3. Optimal effects from the use of an ice pack occur when it is applied for 20 to 30 minutes and then removed for at least 20 minutes before being reapplied. 4.An ice pack that is provided now for use in 20 minutes would be melted before being used.

A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. How should the nurse respond to this request? 1. "I will get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4."I will bring you an extra so that you can change it when you are ready."

Answer: 3 Explanation: 1. The client's partner or family member, or a nursery nurse, can feed the infant. The client is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time. 2. The placenta might be sent to pathology after it is removed, but preparing the client for manual removal of the placenta now is a higher priority. 3. The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary. 4.Antiembolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, antiembolism stockings are not needed for this client because manual removal of the placenta is not major surgery and does not lead to postprocedure immobility.

A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority? 1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV of lactated Ringer solution. 4.Apply antiembolism stockings.

Answer: 3 Explanation: 1. A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal bradycardia is a critical indicator of prolapsed cord. 2. Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is associated with maternal hemorrhage and failed placental separation after birth. 3. The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed. 4.The occiput anterior (OA) fetal position is amenable to delivery and would not represent a barrier to labor.

A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor? 1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4.Occiput anterior (OA) fetal position

Answer: 3 Explanation: 1. Midline episiotomy is straight back from the vagina toward the rectum. 2. Episiotomies are not cut anteriorly toward the urethra. 3. Mediolateral episiotomy is angled from the vaginal opening toward the buttock. 4.Extension into the rectum is a fourth-degree laceration.

A client who received a mediolateral episiotomy to facilitate vacuum extraction birth asks what kind of episiotomy was performed. How should the nurse explain the location of the episiotomy? 1. "It goes straight back toward your rectum." 2. "It is from your vagina toward the urethra." 3. "It is cut diagonally away from your vagina." 4."It extends from your vagina into your rectum."

Answer: 71 kg Explanation: A total weight gain of 40 to 45 lb with a 24-lb gain by 24 weeks is recommended for a client with a multiple-gestation pregnancy. To calculate the client's weight, first determine the prepregnancy weight in pounds by multiplying the weight in kilograms by 2.2, or 60 × 2.2 = 132 lb. If the weight gain should be 24 lb by week 24, add 24 lb to 132, or 132 + 24 = 156. Then divide the weight in kilograms by 2.2, or 156/2.2 = 70.9 or 71 kg.

A client who weighed 60 kg before becoming pregnant with twins is having a routine prenatal examination at gestational week 24. What should be this client's weight in kilograms at this time? (Round to the nearest whole number.)

Answer: 4 Explanation: 1. A client with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean section. This client should either be given only clear liquids or be NPO to reduce the risk of aspiration should a cesarean section need to be performed. 2. The cervix is normally assessed when the client's labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a client was in the active phase of labor and cephalopelvic disproportion was a risk. Every 8 hours is too far apart. 3. Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority. 4.Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.

A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time? 1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4.Assist the client to squat during the second stage.

Answer: 21 g Explanation: The client received 4 g of magnesium sulfate at 1600 hours, followed by 2 g every hour beginning at 1700 hours to 0130 hours. This is a total of 8.5 hours of receiving the medication. The amount of medication provided is 4 g + (2 g × 8.5) = 4 + 17 = 21 g.

A client with premature rupture of membranes received 4 g of magnesium sulfate at 1600 hours, followed by 2 g/hr beginning at 1700 hours. Birth occurred at 0130 hours. How many grams of magnesium sulfate did this client receive? Calculate to the nearest whole number.

Answer: 1 Explanation: 1. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus. 2. Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk. 3. Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus. 4.Shoulder dystocia is more common among large fetuses, and a broken clavicle could result.

A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed? 1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4."His shoulders could get stuck and a collar bone broken."

Answer: 1, 3, 4 Explanation: 1. Abruptio placentae can cause anxiety for both the client and fetus. 2. There is no information regarding the gestational age of this client. The fetus may not be premature. 3. Maternal mortality and perinatal fetal mortality are concerns due to blood loss. 4. Maternal mortality and perinatal fetal mortality are concerns due to hypoxia. 5.Abruptio placentae is a premature separation of the placenta, not a genetic abnormality.

A multigravida client with suspected abruptio placentae is admitted in active labor. Which nursing diagnoses should the nurse identify as appropriate for this client? Select all that apply. 1. Anxiety related to concern for own safety 2. Ineffective Coping related to premature birth 3. Fluid Volume, Risk for Deficit, related to hypovolemia 4. Tissue Perfusion, Risk for Altered, related to blood loss 5.Knowledge Deficit related to lack of information about inherited genetic defects

Answer: 3 Explanation: 1. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 2. An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 3. This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture. 4.The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way.

A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4.Monitor maternal blood pressure every 15 minutes.

Answer: 3 Explanation: 1. This describes a marginal placenta separation, grade 1. 2. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues. 3. With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding. 4.This describes a marginal placenta separation, grade 1.

A pregnant client is diagnosed with central abruptio placentae. What can the nurse infer about the client's condition? 1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding. 2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage. 3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding. 4.Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding.

Answer: 2 Explanation: 1. Contractions are not associated with cervical insufficiency. 2. Cervical insufficiency is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix. 3. Cervical pain is not a manifestation of cervical insufficiency. 4.Contractions are not associated with cervical insufficiency.

A pregnant client is diagnosed with cervical insufficiency. How should the nurse expect this client to explain symptoms of this condition? 1. "I've been having contractions every 4 hours." 2. "I'm not having any pain and I do not feel any contractions." 3. "My cervical pain has gotten much worse over the past 2 days." 4."I'm not having any pain, but my contractions are getting stronger."

Answer: 1, 2 Explanation: 1. Transabdominal cerclage placement typically results in a cesarean section birth. 2. Transabdominal cerclage placement requires a laparotomy for placement and removal. 3. Transabdominal cerclage placement does not increase the risk for hydramnios. 4. Transabdominal cerclage placement does not increase the risk for abruptio placentae. 5. Transabdominal cerclage placement does not increase the risk for premature rupture of membranes.

A pregnant client is scheduled for a transabdominal cerclage. What teaching information should the nurse prepare for this client? Select all that apply. 1. Cesarean section birth 2. Preoperative laparotomy 3. Potential for hydramnios 4. Risk for abruptio placentae 5. Premature rupture of membranes

Answer: 2, 4, 3, 5, 1 Explanation: 1. After applying oxygen the healthcare provider should be notified. 2. Nursing management of adverse effects begins by discontinuing the IV oxytocin infusion. 3. After intravenous fluids are started, the client should be turned onto the side. 4. After the oxytocin infusion is discontinued, the primary intravenous solution should be opened up for immediate infusion. 5. After positioning on the side, oxygen by tight face mask at 8 to 10 L/min should be administered.

A pregnant client receiving oxytocin for labor induction begins demonstrating adverse effects of the medication. In which order should the nurse provide care to this client? 1. Notify the healthcare provider. 2. Discontinue the oxytocin infusion. 3. Position the client onto the left side. 4. Infuse prescribed intravenous fluids. 5. Administer oxygen 8 to 10 L per tight face mask.

Answer: 2 Explanation: 1. The non-stress test is a commonly used assessment for the postterm fetus. 2. A postterm pregnancy is high risk. Fetal assessments must be obtained to verify fetal well-being or the need for delivery via induction or cesarean. One week is too long a time period between assessments. 3. A biophysical profile is a commonly used assessment for the postterm fetus. 4.Labor induction is likely to occur with postterm pregnancies because the aging placenta becomes less efficient at transporting oxygen and nutrients and because the risk of fetal macrosomia increases with length of gestation.

A primiparous client is at 42 weeks' gestation. What order should the nurse question? 1. Begin non-stress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4.Schedule labor induction for tomorrow.

Answer: 1 Explanation: 1. Rheumatic fever is not a strep infection of the heart but an autoimmune connective tissue disease in response to a previous strep infection. This statement requires clarification. 2. This statement is correct. No further clarification is needed. 3. This statement is correct and needs no clarification. 4.Children who have had one episode of rheumatic fever are at greater risk for future episodes. In addition, long-term valve damage may occur. This statement needs no further clarification.

A school-age client is diagnosed with rheumatic fever. Which parental statement indicates the need for further education by the nurse? 1. "I understand rheumatic fever is a strep infection of the heart." 2. "My child will be on bed rest for several weeks." 3. "My child will be treated with aspirin and/or corticosteroids." 4."Once my child has recovered, she will still need to be monitored for sequelae to the disease."

Answer: 4 Explanation: 1. These are not manifestations of an infection. 2. Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium. The major complications of placenta accreta include maternal hemorrhage and failure of the placenta to separate following birth of the infant. 3. The client is hypotensive. 4.Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.

After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing? 1. Infection 2. Placenta accreta 3. Hypertensive crisis 4.Amniotic fluid embolus

Answer: 1, 2, 3 Explanation: 1. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 2. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 3. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in kneechest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 4. The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed. 5.Benadryl is not appropriate for this child.

An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. 1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered. 4. Draw blood for a serum hemoglobin. 5.Administer diphenhydramine (Benadryl) as ordered.

Answer: 3 Explanation: 1. Calcium channel blockers may be used to treat hypertension. 2. Lovastatin is given to reduce serum cholesterol level. 3. Cyclosporin A is given to prevent rejection. 4.An antibiotic may be given to treat an infection.

Which parental statement regarding the use of cyclosporin A after a heart transplant indicate correct understanding of the information presented by the nurse? 1. "This medication is used to treat hypertension." 2. "This medication is used to reduce serum cholesterol level." 3. "This medication is used to prevent rejection." 4."This medication is used to treat infections."

Answer: 4 Explanation: 1. A periurethral laceration is near the urethra. 2. A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle. 3. A fourth-degree laceration is through the rectal mucosa. 4.A third-degree laceration includes the rectal sphincter.

For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. What should the nurse include when explaining the location of the episiotomy to the client? 1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4."Through your rectal sphincter."

Answer: 4 Explanation: 1. Hydramnios is not suspected simply by virtue of a twin gestation. 2. A quadruple screen is not used to determine hydramnios. 3. Hydramnios occurs when there is more amniotic fluid than normal for gestation. 4.The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation.

For which reason should the nurse suspect hydramnios in a pregnant client? 1. The client is pregnant with twins. 2. The quadruple screen comes back positive. 3. There is less amniotic fluid than normal for gestation. 4.The fundal height increases disproportionately to the gestation.

Answer: 4 Explanation: 1. Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This client will be grieving but is not experiencing physical complications. 2. Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This client might be experiencing a complication, but it is a lower priority than the client with the possibility of a prolapsed cord. 3. Although this client is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency. 4.Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.

The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention? 1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4.Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."

Answer: 3 Explanation: 1. Future pregnancies are not limited to one. 2. Attempting a vaginal birth is contraindicated, and future births will be planned cesareans. 3. A classic uterine incision is made in the upper uterine segment and holds an increased risk of rupture in subsequent pregnancy, labor, and birth. 4.Future pregnancies are not prohibited.

The client is instructing a client recovering from a classic uterine incision for a cesarean birth. Which statement indicates that the client understands implications for future pregnancies that are secondary to this type of incision? 1. "I can only have one more baby." 2. "The next time I have a baby, I can try to deliver vaginally." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4."The risk of rupturing my uterus is too high for me to have any more babies."

Answer: 4 Explanation: 1. An uncomplicated elective cerclage may be done as an outclient. 2. An emergency cerclage requires hospitalization for 5 to 7 days or longer. 3. After 37 completed weeks' gestation, the suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed. 4.Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure.

The clinical instructor reviews postoperative care of cerclage with a group of nursing students. Which student statement indicates the need for further information? 1. "Sometimes cerclage can be performed on an outclient basis." 2. "If cerclage is performed emergently, the client will usually be hospitalized for at least 5 days." 3. "After 37 weeks' gestation, the client's cerclage may be cut in order to allow for vaginal delivery." 4."If the client's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed."

Answer: 2 Explanation: 1. Amniotomy is an accepted method of labor augmentation. 2. Following .AROM, because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal examinations must be kept to a minimum to reduce the chance of introducing an infection. 3. Women need to know that amniotic fluid is constantly produced because some women may worry that they will experience a "dry birth." 4.In all cases, the .FHR is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared.

The clinical nurse coordinator is reviewing the care of clients who undergo artificial rupture of membranes (AROM) by way of amniotomy with a group of nursing students. Which student statement indicates that the teaching has been effective? 1. "Amniotomy is contraindicated for use in labor augmentation." 2. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." 3. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'" 4."In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed."

Answer: 3 Explanation: 1. Preeclampsia is not diagnosed until the 20th week of gestation. This client is only at 18 weeks. Further, blood pressure can be assessed in either arm when the client is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm. 2. Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time. 3. A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth. 4.Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those that are spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.

The home health nurse is visiting the home of a client who is 18 weeks pregnant with twins. Which nursing action is most important? 1. Assess the client's blood pressure in the upper right arm. 2. Collect a cervicovaginal fetal fibronectin (fFN) specimen. 3. Teach the client about foods that are good sources of protein. 4.Determine whether the pregnancy is a result of infertility treatment.

Answer: 2 Explanation: 1. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions. 2. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow. 3. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority. 4.Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the client is hypotensive. Decreasing the IV rate will not improve fetal heart tones.

The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important? 1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4.Decrease the IV of lactated Ringer solution to 50 mL/hour.

Answer: 2 Explanation: 1. Women with intrauterine fetal demise can demonstrate signs of an infection; however, this temperature is not high enough to indicate this problem. 2. Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level and indicates that the client is in DIC. 3. Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this is a normal platelet count. 4.Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is a higher priority.

The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention? 1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4.Family refusing fetal autopsy

Answer: 4 Explanation: 1. Ventricular septal defects do not cause pain, fever, or deficient fluid volume. 2. Ventricular septal defects do not cause pain, fever, or deficient fluid volume. 3. VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis. 4.Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.

The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child? 1. Hypothermia related to decreased metabolic state 2. Acute Pain related to the effects of a congenital heart defect 3. Ineffective Tissue Perfusion (peripheral) related to cyanosis secondary to congenital heart defect 4.Impaired Gas Exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Answer: 3 Explanation: 1. Grade 1 abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority. 2. Late decelerations are an abnormal finding, but put only the fetus at risk. This client is not the highest priority. 3. Bleeding with a placenta previa is a complication that can be life threatening to both the mother and baby. This client is the highest priority. 4.Although pregnancy-induced hypertension increases the risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority.

The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first? 1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push 2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 4.37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously

Answer: 1, 2, 5 Explanation: 1. The presence of prolonged decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 2. The presence of persistent late decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 3. Fetal activity is not used as an indication for intrauterine resuscitation. 4. A fetal heart rate of 140 bpm is within normal limits. 5. The presence of persistent and severe variable decelerations is a sign of monreassuring fetal status. Intrauterine resuscitation should be started without delay.

The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply. 1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations

Answer: 2 Explanation: 1. Second- and third-trimester bleeding increases the risk for PPROM. 2. There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM. 3. A urinary tract infection (UTI) increases the risk for PPROM. 4.Multifetal gestation increases the risk for PPROM.

The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? 1. "If I have bleeding in the third trimester of my next pregnancy, I might rupture membranes again." 2. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 3. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 4."If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured."

Answer: 2, 3, 4 Explanation: 1. The fetus should not be removed from the room unless the client asks that the fetus be removed. 2. The fetus should be bathed/cleansed and wrapped in a blanket in preparation for viewing. 3. The client should be asked her preference for viewing and holding the baby. 4. It is inappropriate for the nurse to instruct the client on home care needed after delivery at this time. The client and family are having a highly emotional experience which should not be ignored. 5. Oftentimes other family members will be present and they should be asked of their desire to spend time with the baby.

The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply. 1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby.

Answer: 2 Explanation: 1. This assessment is not called for at this time. 2. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated. 3. Pain medication is a low priority at this time. 4.Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.

The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time? 1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4.Assess the odor of the amniotic fluid.

Answer: 2, 3, 5 Explanation:1. Flushing is a maternal adverse effect of magnesium sulfate. 2. Fetal side effects of magnesium sulfate may include lethargy that persists for 1 or 2 days following birth. 3. Fetal side effects of magnesium sulfate may include hypotonia that persists for 1 or 2 days following birth. 4. Poor sucking reflex is not an adverse effect of magnesium sulfate. 5. Respiratory depression in the newborn can also occur after maternal magnesium sulfate.

The nurse is caring for the newborn of a client who received magnesium sulfate for preterm labor. Which fetal effects should the nurse attribute to the client's medication treatment? Select all that apply. 1. Flushing 2. Lethargy 3. Hypotonia 4. Poor sucking reflex 5. Respiratory depression

Answer: 3 Explanation: 1. Healing episiotomies can be very painful, and pain medication should be provided for clients experiencing pain. 2. Warm tub baths are helpful to facilitate both comfort and healing of an episiotomy. 3. This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum. 4.When a client has an episiotomy, perineal hygiene is important to prevent infection and facilitate healing.

The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement indicates that further information is required? 1. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 2. "Soaking in the tub will help my mediolateral episiotomy to heal." 3. "The tear I have through my rectum is unrelated to my episiotomy." 4."Because I have a midline episiotomy, I should keep my perineum clean."

Answer: 3 Explanation: 1. This is less than recommended for a twin-gestation pregnancy. 2. This is less than recommended for a twin-gestation pregnancy. 3. This is the recommended caloric and protein intake in a twin-gestation pregnancy. 4.This is recommended if the twins are underweight.

The nurse is counseling a newly pregnant gravida 1 at 8 weeks' gestation with twins about the need for increased caloric intake. What should the nurse emphasize as being the minimum recommended intake? 1. 2500 kcal and 120 g protein 2. 3000 kcal and 150 g protein 3. 3500 kcal and 175 g protein 4.4000 kcal and 190 g protein

Explanation: The Sellheim incision is a vertical incision in the lower uterine segment.

The nurse is instructing a pregnant client scheduled for an elective cesarean birth on the different types of incisions. Where should the nurse identify the location of the Sellheim incision during this teaching?

Answer: 1 Explanation: 1. Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern. 2. Hypertension does not impact labor pattern; this client has no risk factors for either hypertonic or hypotonic labor pattern development. 3. Although this client is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this client has no risk factors for an abnormal labor pattern. 4.This client has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development.

The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4.30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz

Answer: 4, 5 Explanation: 1. Multiparity does not cause the same release of thromboplastin that triggers DIC. 2. Preterm labor does not cause the same release of thromboplastin that triggers DIC. 3. Diabetes does not cause the same release of thromboplastin that triggers DIC. 4. Abruptio placentae leaves intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. 5.In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC.

The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. What risk factors should the nurse include about this health problem? Select all that apply. 1. Multiparity 2. Preterm labor 3. Diabetes mellitus 4. Abruptio placentae 5.Prolonged retention of a fetus after demise

Answer: 2 Explanation: 1. Vaginal examination is unnecessary when CPD is present. 2. Fetal heart tones are assessed just prior to the start of surgery because the supine position can lead to fetal hypoxia. 3. Maternal temperature is monitored by anesthesia personnel. 4.Maternal urine output is not significant at this point.

The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. What is the last assessment that the nurse should make before the client is draped for surgery? 1. Vaginal examination 2. Fetal heart tones 3. Maternal temperature 4.Maternal urine output

Explanation: 1. This is an image of a circumvallate placenta where a double fold of chorion and amnion form a ring around the umbilical cord, on the fetal side of the placenta. 2. This is an image of a battledore placenta where the umbilical cord is inserted at or near the placental margin. 3. This is an image of a succenturiate placenta where one or more accessory lobes of fetal villi develop on the placenta. 4. This is an image of velamentous insertion of the umbilical cord where the vessels of the umbilical cord divide some distance from the placenta in the placental membranes.

The nurse is preparing instruction on placental and umbilical cord variations. Which diagram should the nurse use to explain succenturiate placenta?

Answer: 1, 2, 3 Explanation: 1. Absolute contraindications for the use of misoprostol include fetal tachycardia. 2. Absolute contraindications for the use of misoprostol include a history of previous cesarean birth. 3. Absolute contraindications for the use of misoprostol include the presence of uterine contractions 3 times in 10 minutes. 4. Evidence of maternal preeclampsia or eclampsia is not an absolute contraindication for the use of misoprostol. 5. Absolute contraindications for the use of misoprostol include the presence of placenta previa, not a history of placenta previa with a previous pregnancy.

The nurse is reviewing the medical history of a pregnant client being considered for cervical ripening. Which data indicate that the order for misoprostol (Cytotec) should be reconsidered? Select all that apply. 1. Current fetal heart rate is tachycardic. 2. Client had one cesarean live birth 3 years ago. 3. Uterine contractions are occurring every 2 minutes. 4. Client has 2+ pedal edema and elevated blood pressure. 5. There is a history of placenta previa with one previous pregnancy.

Answer: 4 Explanation: 1. This client has no contraindication to ECV. 2. Although this client is less likely to have a successful ECV this week if it were unsuccessful last week, there is no contraindication to attempting the procedure. 3. This client has no contraindication to ECV. 4.ECV is not attempted until 36 weeks. This client is too early in her pregnancy for ECV.

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. "Multipara, transverse lie." 2. "Primipara failed ECV last week." 3. "Primipara, frank breech ballotable." 4."Multipara, 32 weeks, complete breech."

Answer: 2 Explanation: 1. A repeat cesarean must be able to be performed immediately to safely attempt a VBAC. Many small and rural hospitals do not have surgical and anesthesia staff available at night or on weekends and holidays, and therefore do not allow clients to have a VBAC. 2. Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classic vertical incisions on the uterus have a higher rate of rupture and should not be attempted. 3. The incidence of uterine rupture is 0.5% to 0.9%. Women who have a successful VBAC have lower incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays. 4.Nonrepeating conditions such as any nonvertex presentation might make VBAC a viable option as long as this pregnancy is vertex.

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which participant statement indicates that additional information is needed? 1. "Because my hospital is so small and in a rural area, they will not let me attempt a VBAC." 2. "Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 3. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." 4."My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down."

Answer: 3, 1, 2 Explanation: 1. The ductus arteriosus connects the pulmonary artery to the aorta and is the last structure that blood reaches. 2. The ductus venosus connects the umbilical vein to the inferior vena cava bypassing the liver. It is the first structure that blood reaches. 3.The foramen ovale connects the right atrium to the left ventricle and bypasses the lungs. It is the second structure that blood reaches.

The nurse is teaching a pregnant client about fetal circulation. Which is the correct sequence of blood flow that indicates the pregnant client understands the information presented? 1. Ductus arteriosus 2. Ductus venosus 3.Foramen ovale

Answer: 2 Explanation: 1. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head. 2. The client should only push during contractions, not between contractions. 3. These are normal fetal heart tones. No intervention is needed. 4.Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.

The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention? 1. Bladder is emptied using a straight catheter. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4.Regional anesthesia is administered via pudendal block.

Answer: 2 Explanation: 1. Positioning on the left side will not change the fetal position. 2. The fetus is in the transverse lie. The client needs to be prepared for a cesarean birth. 3. Placing a wedge under the right hip will not change the fetal position. 4. The client is not in any acute distress. Intravenous fluid bolus and oxygen are not required.

The nurse palpates the following when conducting a vaginal assessment on a client in labor: What action should the nurse take to address this finding? 1. Position the client on the left side. 2. Prepare the client for cesarean section. 3. Place a wedge under the client's right hip. 4. Increase intravenous fluids and apply oxygen.

Answer: 1 Explanation: 1. In a marginal placenta previa, the edge of the placenta is covered. 2. The internal os is completely covered in a complete placenta previa. 3. The internal os is partially covered in a partial placenta previa. 4. In a low-lying placenta previa, the placenta is implanted in the lower uterine segment but does not cover the os.

The nurse selects the following diagram to instruct a pregnant client with placenta previa. What should the nurse specifically teach the client about this health problem? 1. The edge of the placenta is covered. 2. The placenta completely covers the internal os. 3. The placenta is implanted with partial covering of the internal os. 4. The placenta is implanted in the lower uterine segment not covering the os.

Answer: 2 Explanation: 1. This is not a complication of cesarean birth by request. 2. Placenta implantation problems are more common after cesarean birth and increase healthcare costs because of the high-risk care and testing required. 3. Which anesthesia method is used is not a significant factor in healthcare costs of cesarean birth by request. The need for anesthesia, use of the operating suite, equipment use, personnel, and other factors are more responsible for greater costs of cesarean birth compared with vaginal birth. 4.The income of the couple does not affect healthcare costs directly.

The risk management nurse is reviewing labor and delivery statistics over the last 2 years in an effort to decrease costs of maternity care. What finding contributes to increased healthcare costs in clients undergoing cesarean birth by request? 1. Prolonged anemia, requiring blood transfusions every few months 2. Increased abnormal placenta implantation in subsequent pregnancies 3. Decreased use of general anesthesia with greater use of epidural anesthesia 4.Coordination of career projects of both partners leading to increased income

Answer: 4 Explanation: 1. Overall labor is often prolonged, not precipitous. 2. Overall labor is often prolonged, not more rapid. 3. Overall labor is often prolonged, not shorter. 4.The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor.

What should the nurse anticipate the labor pattern for a fetal occiput posterior position to be? 1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4.Prolonged with regard to the overall length of labor

Answer: 1, 2, 3, 4 Explanation: 1. As soon as the fetus is term, induction is typically scheduled because the fetus is at an increased risk for intrauterine fetal demise. 2. Decreased amniotic fluid can contribute to fetal head compression, which can manifest itself as early decelerations. 3. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. 4. Less amniotic fluid lessens the cushioning effect, and cord compression is more likely. 5.Labor progress is slower than average due to the decreased fluid volume.

When caring for a client with oligohydramnios, on what should the nurse focus? Select all that apply. 1. Induction is typically scheduled. 2. Early decelerations are more likely. 3. Fetal pulmonary hypoplasia can develop. 4. There is an increased risk of cord compression. 5.Labor progress is often more rapid than average.

Answer: 4 Explanation: 1. The parents know the name of the surgeon. It will mean nothing to a 4-year-old child. 2. The child will be asleep during surgery and therefore does not need to know about the procedure. 3. This is beyond the understanding of a 4-year-old. 4.The child should be prepared in terms of what she will see, hear, smell, or feel.

Which age-appropriate information should the nurse provide to a 4-year-old girl who is being emotionally prepared for open heart surgery? 1. The name of the surgeon who will be performing the procedure 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine used during the procedure 4.What the environment will look and sound like when the child wakes up

Answer: 1, 3, 4 Explanation: 1. Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume. 2. Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate. 3. Tachycardia is an early compensatory mechanism for hypovolemia in a child. 4. Decreased capillary refill time would be an early indicator of decreased fluid volume and compensation. 5.Decreased blood pressure is a later finding and would not occur until other compensatory mechanisms were exhausted.

Which assessment data would cause the nurse to suspect that a pediatric client is experiencing hypovolemic shock? Select all that apply. 1. Dyspnea 2. Bradycardia 3. Tachycardia 4. Capillary refill time greater than 3 seconds. 5.Blood pressure 72/42 mmHg

Answer: 2 Explanation: 1. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. 2. The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than 3 seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. 3. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. 4.If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.

Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization? 1. Capillary refill is greater than 3 seconds. 2. Lower extremities are warm, with a capillary refill of less than 3 seconds. 3. Sensation is decreased with a weakened dorsalis pedis pulse. 4.Dorsalis pedis pulse is palpable but posterior tibial pulse is weak.

Answer: 1 Explanation: 1. A child with pulmonary artery hypertension should have exercise tailored to avoid dyspnea, such as golf. 2. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. 3. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. 4.Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

Which athletic activity should the nurse recommend for a school-age child who is diagnosed with pulmonary artery hypertension? 1. Golf 2. Basketball 3. Cross-country running 4.Soccer

Answer: 1, 2, 4 Explanation: 1. Tachycardia is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 2. Weak distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 3. Thready distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. 4. Normal blood pressure for age is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 5.A decrease in systolic blood pressure is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock.

Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with early compensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5.Decrease in systolic blood pressure

Answer: 3, 5 Explanation: 1. Tachycardia is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 2. Weak distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 3. Thready distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. 4. Normal blood pressure for age is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 5.A decrease in systolic blood pressure is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock.

Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with moderate uncompensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5.Decrease in systolic blood pressure

Answer: 1 Explanation: 1. Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. 2. The weight, instead of decreasing, increases, because of retention of fluids. 3. Blood pressure does not increase in CHF. 4.Bradycardia is a serious sign and can indicate impending cardiac arrest.

Which clinical manifestation does the nurse anticipate for a pediatric client who is admitted with congestive heart failure (CHF)? 1. Tachycardia 2. Weight loss 3. Hypertension 4.Bradycardia

Answer: 3, 4 Explanation: 1. High fever is a clinical manifestation anticipated for a pediatric client diagnosed with the acute stage of Kawasaki disease. 2. Diarrhea is a clinical manifestation anticipated for a pediatric client diagnosed with the acute stage of Kawasaki disease. 3. Thrombocytosis is a clinical manifestation anticipated for a pediatric client diagnosed with the subacute stage of Kawasaki disease. 4. Joint pain is a clinical manifestation anticipated for a pediatric client diagnosed with the subacute stage of Kawasaki disease. 5.Beau lines are a clinical manifestation anticipated for a pediatric client diagnosed with the convalescent stage of Kawasaki disease.

Which clinical manifestations does the nurse anticipate for a pediatric client who is diagnosed with the subacute stage of Kawasaki disease? Select all that apply. 1. High fever 2. Diarrhea 3. Thrombocytosis 4. Joint pain 5.Beau lines

Answer: 1, 2, 5 Explanation: 1. Breastfeeding is recommended because it provides antibodies to help protect the infant from infection. 2. Allowing the infant to nurse for more than 30 minutes will burn more calories than calories are gained. 3. The infant should be positioned at a 45-degree angle to reduce the workload of the heart. 4. The formula should not be diluted beyond the label recommendations, as it would lower the caloric count. 5.This is appropriate for the infant with a congenital heart defect as well as the normal infant.

Which feeding techniques should the nurse include in the teaching session for the parents of an infant who is being discharged in order to gain weight for the corrective surgery needed for a congenital heart defect? Select all that apply. 1. Breastfeed if possible. 2. Complete each feeding within 30 minutes. 3. Position the infant flat to promote swallowing. 4. Dilute the formula with extra water to ensure adequate fluid intake. 5.Burp the infant frequently.

Answer: 3 Explanation: 1. These defects are not associated with blood pressures that are different in upper and lower extremities. 2. These defects are not associated with blood pressures that are different in upper and lower extremities. 3. Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. 4.These defects are not associated with blood pressures that are different in upper and lower extremities.

Which heart defect should the nurse suspect for an infant whose upper extremities have stronger pulses than the lower extremities and blood pressure is higher in the arms than in the legs? 1. Transposition of the great vessels 2. Patent ductus arteriosus 3. Coarctation of the aorta 4.Atrial septal defect

Answer: 3 Explanation: 1. The platelets would be normal. 2. The white blood cell count would not be high unless an infection was present. 3. The child's bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects. 4.The hematocrit would not be low.

Which initial laboratory data does the nurse anticipate for a child who is admitted to the hospital with a cyanotic heart defect? 1. A low platelet count 2. A high white blood cell count 3. A high hemoglobin 4.A low hematocrit

Answer: 4 Explanation: 1. Any unexplained fever should be reported. 2. The child should live a normal and active life following repair of a cardiac defect. 3. Immunizations should be provided according to the schedule. 4.Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis, according to the American Heart Association.

Which is an appropriate statement for the nurse to include in the discharge instructions to the parents of a child who is recovering from cardiac surgery? 1. "The child will have a fever for several weeks following the surgery." 2. "The child will be restricted from most play activities." 3. "The child will not receive routine immunizations." 4."The child will receive prophylactic antibiotics prior to any dental procedures."

Answer: 1 Explanation: 1. This situation is an example of cardiac concussion. Survival chances improve if CPR is initiated immediately. 2. Other people can call 911. Cardiac resuscitation must be initiated immediately. 3. This is an appropriate action but not a priority. 4.This type of injury often has no external symptoms of injury.

Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game? 1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4.Assessing for hemorrhage

Answer: 2 Explanation: 1. Airway patency and replacement of volume are priorities before assessing the cause of the bleeding. 2. Airway patency and oxygen delivery (breathing) are always first in the treatment for a client with health concerns. 3. Pain would be a consideration but would not be attended to as a first priority. 4.Replacement of volume is vital but would follow establishing airway and breathing.

Which is the priority nursing action when providing care to a pediatric client who is diagnosed with hypovolemic shock? 1. Assessing the cause of bleeding 2. Establishing an open airway and administering oxygen 3. Administering analgesics for pain control 4.Providing replacement of volume

Answer: 3 Explanation: 1. Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules. 2. Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules. 3. Spironolactone (Aldactone) is a maintenance diuretic that is potassium-sparing. Hypokalemia would increase the risk of Lanoxin toxicity. 4.Angiotensin-converting enzyme (ACE) inhibitors promote vascular relaxation.

Which is the rationale the nurse provides to the parents of an infant diagnosed with congestive heart failure (CHF) for the prescribed spironolactone? 1. Produces rapid diuresis 2. Blocks reabsorption of sodium and water in renal tubules 3. Spares potassium 4.Promotes vascular relaxation

Answer: 4 Explanation: 1. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation. 2. A culture can indicate a current streptococcal infection. 3. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation. 4.The laboratory test for antistreptococcal antibodies is an antistreptolysin-O (ASO) titer.

Which laboratory test does the nurse anticipate for a child who is admitted to the hospital with suspected rheumatic fever? 1. Erythrocyte sedimentation rate 2. Throat culture 3. C-reactive protein 4. Antistreptolysin-O (ASO) titer

Answer: 1 Explanation: 1. This statement is accurate. 2. A stent maintains an opening; it does not close an opening. 3. A stent maintains the ductus as patent. It does not bypass the ventricle. 4.This is not the purpose of the stent.

Which parental statement indicates correct understanding for the reason a cardiac catheterization is needed for a child who is diagnosed with a congenital heart defect? 1. "This procedure will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed." 2. "This procedure is used to close the ductus arteriosus to prevent mixing of arterial and venous blood." 3. "This procedure will redirect the blood so that blood bypasses the right ventricle." 4."This procedure connects the ventricle to the atrium."

Answer: 1, 2, 3, 4 Explanation: 1. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend the use of seasoning substitutes to replace added salt. 2. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should provide a list of foods that are high in sodium. 3. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend a decrease in television screen time. 4. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend an increase in physical activity. 5.Monitoring blood pressure daily is not an activity that reduces the child's likelihood of developing hypertension as an adult.

Which strategies should the nurse recommend for a school-age client who is at risk for developing hypertension as an adult? Select all that apply. 1. Using seasoning substitutes for salt 2. Providing a list of foods high in sodium 3. Decreasing television time 4. Increasing physical activity 5.Monitoring blood pressure daily

Answer: 4 Explanation: 1. Immunizations should be provided according to the schedule. 2. The child should live a normal and active life following repair of a cardiac defect. 3. Fever is not expected for a prolonged period after surgery, and any unexplained fever should be reported. 4.Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis.

Which teaching point should the nurse include in the discharge instructions for a pediatric client who has undergone cardiac surgery? 1. Should not receive routine immunizations. 2. Should be restricted from most play activities. 3. Fever is expected for several weeks following the surgery. 4.Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures.

Answer: 1, 2, 3, 4 Explanation: 1. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 2. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 3. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 4. Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate including the application of ice or iced saline solution to the face to reduce the heart rate. 5.A 10-month-old child cannot be instructed to hold her breath and bear down as with a bowel movement.

Which treatment options should the nurse anticipate for a 10-month-old infant admitted to the emergency department with supraventricular tachycardia? Select all that apply. 1. Administering intravenous adenosine (Adenocard) 2. Administering intravenous amiodarone (Cardarone) 3. Preparing for cardioversion 4. Applying ice to the face 5.Having the child perform a Valsalva maneuver